Of the 186 case reports, 102 (54.8%) were closed access; among the closed-access reports, 66 (65%) case reports had at least 1 image found on Google Images. Of the 83 case reports that were open access, 76 (92%) had at least 1 image found on Google Images. From crude comparisons ( P <.001), it appears that case reports with open access were more likely to have medical images visible as Google Images.
For 76.3% (142/186) of the case reports, at least 1 image was found on Google Images. The odds were higher of finding an image from the case report online if the full-text paper was available on ResearchGate (OR 9.16, 95% Cl 2.71-31.02), PubMed Central (OR 7.90, 95% Cl 2.33-26.77), or Google Scholar (OR 6.07, 95% Cl 2.77-13.29) than if full-text was available solely through an open access journal (OR 5.33, 95% Cl 2.31-12.28), but all factors contribute to increased odds of locating patient images online ( Figure 3 ).
To better understand where Google Images is obtaining patient photographs, information about data sources was extracted from the hyperlink under each of the images that were found online. Raw image sources included the journal website, publisher website, research database (eg, Semantic Scholar), research repository (eg, ResearchGate), social media, and professional associations. These were grouped into 2 main categories—journal websites or other websites (any third-party sources). A total of 51.0% of photographs came from the journal website, and 49.0% were from a third-party site. In 2021, 51.1% were from journal websites, and 48.9% from third-party sites. In 2022, the number of images from journal websites increased to 63.4%, while the number from third-party sites was 36.6%.
Based on generalized estimating equations, after adjusting for individual study differences, compared with the search in 2020, patient photographs were less likely to be found on third-party websites based on the 2022 search results. Specifically, the odds of finding a patient photograph on a third-party site in 2022 were about 40% less likely, compared with the search done in 2020. This finding was statistically significant with OR 0.61, 95% Cl 0.43-0.87. The likelihood of finding a patient photograph on a third-party website was not significantly different between the search in 2021 and the search in 2020 ( Table 2 ).
Search | Odd ratio (95% CI) | value |
2021 vs 2020 | 1.04 (0.78-1.40) | .77 |
2022 vs 2020 | 0.61 (0.43-0.87) | .006 |
The aims of this study were to identify what percentage of patient photographs published in medical case reports were found in Google Images search results, to better understand the relationship between open access publication status and image availability, and to verify whether there is a trend over time for finding patient photographs on third-party websites. Out of the 186 case reports that included clinical photographs, at least 1 photograph from the case report was available on Google Images for 142 (76.3%) references. The odds of finding an image from the case report online were higher if the full-text paper was available on ResearchGate (OR 9.16, 95% CI 2.71-31.02), PubMed Central (OR 7.90, 95% CI 2.33-26.77), or Google Scholar (OR 6.07, 95% CI 2.77-13.29) than if full-text was available solely through an open access journal (OR 5.33, 95% CI 2.31-12.28), but all factors contributed to an increased risk of locating patient images online. This study is the first of its kind to search Google Images for medical photographs from a random sample of case reports; as such there are no studies with which to compare results.
Findings from this study are notably higher than the results from earlier research, where 34 (37%) out of 94 case reports had at least 1 photograph accessible on Google Images [ 3 ]. While the difference in sample population may partially account for the disparity in outcomes, this study identified several additional variables that influenced the availability or unavailability of patient photographs on Google Images. For instance, finding images from the case reports online was more likely if the full-text paper was also available on ResearchGate, PubMed Central, or Google Scholar, compared to case reports solely accessible through open access publications.
To better understand how Google retrieves the images, the image source was recorded for all photographs found on Google Images and these results were compared over a 3-year time period. From 2020 to 2022, there was a notable change in where images were sourced, with a significant decrease in photographs housed on third-party websites such as ResearchGate and Semantic Scholar. This change may be linked to a recent legal judgment where Google was held liable for copyright infringement for displaying content with links to a third-party infringer’s website which was not the original publisher and owner of the copyrighted content [ 20 ].
The systematic, documented approach to searching for patient medical photographs on Google Images is a strength of this study. The primary challenge is that Google Images search results are not stable. Although the team attempted to manage as many factors as possible, including using the Tor browser to control for the influence of team member search histories, search results changed. Investigating the same data set yearly for over 3 years, sometimes the photographs were never found, while others were consistently located. The primary findings in this paper are based on the most recent searches in 2022, as the purpose of this study was not to demonstrate the ways search results change over time, but whether the images were found or not. Search results from 2020, 2021, and 2022 are available on request.
A further limitation is that the team did not investigate other image search engines or social media platforms where patient photographs might also appear. While the team was able to provide clear evidence using Google Images it would be an interesting avenue for future research to explore some alternate image search engines and platforms. In addition, the use of the Tor browser to minimize personalization in search results may not completely replicate the typical user experience and may have introduced a form of selection bias.
From a clinical standpoint, the availability of patient photographs on Google Images presents both advantages and risks. Results demonstrated a high proportion of medical photographs from case reports on Google Images. While this concentration allows for wider accessibility and educational benefits, the public availability of these sensitive images online also raises ethical concerns with respect to the privacy of personal health information. Patients should be adequately informed about the possible impacts of providing consent for clinicians to publish their images in medical journals. Even if clinicians seek consent for their publication in case reports, it is not clear whether patients are informed about the possibility of photographs becoming available on Google Images and reaching unintended audiences, including the media and the general public. Similarly, it is not known whether clinicians themselves are aware of these risks. As such, they may not be in a position to ensure informed consent from their patients regarding the potential availability of their clinical images online. A recent content analysis of journal consent forms for the publication of patient photographs found that 55.5% (10/18) of consent forms related to 132 journals mentioned photographs being available to an audience outside of the journal website, but only 16.7% (3/18) addressed the possibility of the patient’s images being linked to journal or publisher social media platforms [ 21 ].
A lack of standardized guidelines poses a challenge to obtaining patient consent for publishing case reports with photographs. In addition to the policy and practice recommendations highlighted in earlier research, current findings underline the need for increased dialogue among academics, patients, governments, and industry. Discussions should focus on improving the consent process and establishing consistent practices and policies for publishing case reports with patient photographs. Study findings indicate that patient photographs are accessible on Google Images, even when published in closed-access case reports. Engagement with Google and other major online image repositories is critical to raise awareness of this issue and to seek input regarding the underlying causes and potential solutions. New policies should be implemented to ensure that patients are protected and that all stakeholders are aware of the risks involved in submitting clinical photographs to online medical journals. Accordingly, the next phase of this study focuses on qualitative interviews with case report authors, journal editors, publishers, and patients. The goal is to identify potential solutions to this complex ethical challenge, including responsive policies that will influence practices across academic publishing to maintain patient privacy.
The Natural Sciences and Engineering Research Council of Canada (554764-2021) provided student scholarship funding. The funders had no role in study design, in collection or interpretation of data, in writing the report, or in the decision to submit the paper for publication.
The data sets generated and analyzed during this study are available from the corresponding author on reasonable request.
ZM was responsible for conceptualization (lead), investigation (lead), methodology (equal), supervision (lead), writing—original draft preparation (lead), and writing—review and editing (lead). MB carried out the investigation (equal), project administration (equal), writing—original draft preparation (equal), and writing—review and editing (equal). MW contributed to the formal analysis (lead), methodology (equal), visualization (lead), writing—original draft preparation (equal), and writing—review and editing (supporting). AC did the investigation (equal), writing—original draft preparation (equal), and writing—review and editing (supporting). HJ did the investigation and writing—review and editing (supporting). SA aided in conceptualization (supporting), methodology (equal), writing—original draft preparation (equal), and writing—review and editing (supporting). RP contributed to the investigation (equal), project administration (equal), and writing—review and editing (supporting). VB performed the investigation (equal), project administration (equal), writing—original draft preparation (equal), and writing—review and editing (supporting). VFR did the investigation (equal), project administration (equal), and writing—review and editing (supporting). BC performed the investigation (equal) and writing—review and editing (supporting). LA performed the investigation (equal) and writing—review and editing (supporting). MS contributed to the methodology (equal) and writing—review and editing (supporting). VW aided in conceptualization (supporting), methodology (equal), and writing—review and editing (supporting). FB was involved in conceptualization (supporting) and writing—review and editing (supporting). CK contributed to the conceptualization (supporting) and writing—review and editing (supporting).
None declared.
Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) cross-sectional checklist.
Case Report |
Committee on Publication Ethics |
odds ratio |
Strengthening the Reporting of Observational Studies in Epidemiology |
Edited by T de Azevedo Cardoso; submitted 13.12.23; peer-reviewed by M Roguljić, D Singh; comments to author 08.03.24; revised version received 08.04.24; accepted 24.04.24; published 24.06.24.
©Zack Marshall, Maushumi Bhattacharjee, Meng Wang, Abdul Cadri, Hannah James, Shabnam Asghari, Rene Peltekian, Veronica Benz, Vanessa Finley-Roy, Brynna Childs, Lauren Asaad, Michelle Swab, Vivian Welch, Fern Brunger, Chris Kaposy. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 24.06.2024.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research (ISSN 1438-8871), is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.
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