The Quality of Internet Advertising in Aesthetic Surgery: An In-Depth Analysis

Abstract

Background: The aesthetic market is a growing business, as evidenced by the American Society for Aesthetic Plastic Surgery (ASAPS) reporting an increase of 147% in the number of cosmetic procedures performed by members since 1997. This market is consumer-oriented, relying heavily on advertising for survival amid the increasing provider competition.

Objectives: The authors evaluate trends, ethics, and efficacy of Internet advertising in aesthetic surgery.

Methods: Medical cosmetic providers in Southern California and their Web sites were catalogued through sales lists from manufacturers (Medicis and Allergan) and combined with advertised providers of surgical treatments. Using the ASAPS/American Society of Aesthetic Plastic Surgeons (ASPS) and American Medical Association Codes of Ethics as guidelines, scores were assigned to each Web site and evaluated with the provider’s board certification. A geographical analysis determined whether the presence of high numbers of competitors had an impact on the adherence to ethical guidelines for advertising. To examine patient preferences in physician advertising, a survey was conducted online.

Results: Board-certified plastic surgeons showed the highest total ethical scores, followed by otolaryngologists, oromaxillofacial surgeons, and ophthalmologists. No decrement in the quality of the advertising was found in densely competitive environments. A consistent correlation was found between superior compliance with ethical guidelines and board certification in plastic surgery. The patient preference survey of 208 individuals demonstrated their desire for a well-trained, board-certified plastic surgeon to perform their cosmetic procedures.

Conclusions: Although plastic surgeons demonstrate greater overall compliance with the ASAPS/ASPS Advertising Code of Ethics, they can continue to improve. With the large variety of cosmetic physicians offering the same procedures, maintaining open, honest, and forthright communication with the public is essential.

For decades, there have been many discussions surrounding the practice of physicians advertising their cosmetic services to the public. Some have perceived this activity as questionable, stating that such promotion consequently tarnishes physicians’ public image.^1,2 Others have defended advertising as merely an introduction to the public, with the possibility of increasing demand for physician services.³ As the world has come to rely increasingly on the Internet, consumers’ attention has become diverted to electronic advertisement, and the traditional ideal of a physician’s office and staff being solely sufficient to “sell” the practice has fallen by the wayside.

By the turn of the 21st century, the Internet had revolutionized the way people managed their businesses, obtained information, communicated, and shopped for goods and services. With the vast information made available through the click of a button, the Internet has an excellent capability to reach more potential patients than traditional print advertising. For this reason, in recent years, physicians have turned to electronic media for a boost in patient volume. Providers of cosmetic procedures are no exception. The aesthetic market is a growing business; last year, the American Society for Aesthetic Plastic Surgery (ASAPS) reported an increase of 147% in the number of cosmetic procedures performed by members since 1997.⁴ There is fierce competition for cosmetic patients and advertising is widespread.⁵ Patients seeking elective cosmetic procedures now are considered more than patients; they are customers.⁶ Cosmetic surgery practices are inherently very service oriented, as the services rendered are not generally covered by health insurance and therefore require patients to spend out-of-pocket funds.⁷

This electronic highway has emerged as the method of choice for many providers, as Web sites are easily maintained and quickly updated, cost less than printed materials, and allow consumers to access an unprecedented amount of detailed, readily-available information.⁶ Cosmetic providers of all training backgrounds have begun to tap into the public’s undeniable reliance on the Web to bring in more business.

In this study, different aspects of Internet advertising in the cosmetic market were evaluated. The Web sites of each cosmetic provider in Southern California were assigned objective scores based on ethical codes that have been adopted by the ASAPS, ASPS, and the American Medical Association (AMA; Table 1). Subsequently, the resulting scores were analyzed according to the training background of each provider and their geographical location. Last, patient preferences in Internet-based advertising were investigated with an online survey.

Methods

Ethical Code Scores of Cosmetic Providers

A list of Southern California cosmetic providers was generated from sales lists provided by manufacturers (Medicis and Allergan), an Internet search engine,² and various Web sites.^8-11 A 120-mile radius encompassing San Diego and Los Angeles served as the search area. Cosmetic providers were categorized according to their specialty training as specified in the American Board of Medical Specialties (ABMS)¹² and the Medical Board of California¹³ databases. Several physicians who neither had a board specialty listed in these databases nor had accessible curriculum vitae were categorized as “unknown.” A popular search engine² was employed to search for Web sites promoting cosmetic physicians and their services. Medical cosmetic providers who had a hospital-based or large multispecialty medical group-based Web page were excluded, as they were likely to have little autonomy over advertising decisions.

ASPS and ASAPS have adopted the same code of ethics to promote ethical behavior by its plastic surgery members.¹⁴ Each qualifying Web site was exhaustively evaluated with “Part A” of the ASAPS/ASPS ethical code and a modified ASAPS/ASPS ethical code, the latter including the addition of AMA ethical code elements. A “1” and “0” were given for each ethical component that was met or not met, respectively. To investigate which category of providers had the highest total ethical scores and modified ASAPS/ASPS ethical scores, their training backgrounds were analyzed with our results. Specialties with fewer than 10 Web sites were not included in analysis, as these were considered insufficient to represent their entire specialty.

Geographical Competition and Ethical Code Scores

The degree of compliance with the advertising guidelines of each cosmetic provider was mapped with ESRI ArcGIS to evaluate whether increased density of competition had any effect on the level of professionalism in advertisements for cosmetic surgery.

Patient Preference in Advertising Survey

To obtain preferences of potential patients in plastic surgery advertising, 208 individuals completed a questionnaire (Table 2). This was made available to the general public with an online survey website, www.esurveyspro.com. Participants were asked to select all applicable choices from an answer bank, each bank including the option “Other (please specify),” where they had the opportunity to provide their own answer if their preferred answer was not listed.

Results

Ethical Code Scores of Cosmetic Providers

Of the 2001 cosmetic providers in Southern California, 1307 had Web sites advertising themselves and their services (Table 3). In 1985, Allen et al¹⁵ reported that 1% of physicians surveyed advertised. If extrapolated to apply to today’s cosmetic providers, the number has increased to 65.3% for advertisements of the Internet sort alone. Eleven of 22 specialties whose providers offered cosmetic services had more than 10 Web sites and were included in analysis. Of all specialties evaluated, the 425 plastic surgeons with Web sites had the highest ASAPS/ASPS and combined ASAPS/ASPS + AMA ethical code scores, followed by otolaryngologists, oromaxillofacial surgeons, and ophthalmologists (Table 4). Plastic surgeons were ranked as superior at providing contact information, board certification, training, procedural listings, publication listings, and clear descriptions of patient images. The remaining cosmetic provider specialties had fewer Web sites and lower average overall scores.

To investigate the discrepancy of the results among the 22 specialties, similarities regarding advertising guidelines within the ethical codes put forth by corresponding national medical societies were analyzed. Of the 18 specialties that had a code of ethics available, only seven had specifically addressed the topic of ethical advertising, including plastic surgery, otolaryngology, oral and maxillofacial surgery, ophthalmology, dermatology, chiropractic, and urology. In general, these seven codes of ethics required their professional members to not deceive or mislead patients with their credentials, photographs, statements, or testimonials. Although it is reassuring that these specialties, a majority of which are surgical, made a greater effort in guiding their providers, none of the codes investigated were nearly as thorough and descriptive as those advocated by the ASAPS and ASPS.

Geographical Competition and Ethical Code Scores

No correlation was observed between assigned ethical scores and the geographical locations of each cosmetic provider (Figures 1 and 2). This demonstrated that providers with high-scoring Web sites practice in both more metropolitan areas and less densely-populated regions. Likewise, those with low-scoring Web sites also practice in regions with less geographical competition.

Patient Preference in Advertising Survey

The group included in the patient preference survey comprised 89 men (average, 53.1 years old; range, 24-72 years old) and 119 women (average, 44.9 years old; range, 21-68 years old). Of these individuals, 27 (12.9%) were health professionals and 29 (13.9%) had undergone some cosmetic procedure in the past. Importantly, more than half of those surveyed (51.5%) had considered undergoing a cosmetic procedure, meaning that there is a large population of potential patients who have been deterred by—as they reported—a wish to remain natural (41.8%), high prices (31.3%), or uncertainty regarding surgical risks (31.3%).

Some major conclusions can be drawn from the results of the survey (Table 5). More than half of those surveyed (60.6%) would access the Internet to uncover more information about a plastic surgeon. However, only 17.3% would select this modality to initially search for a plastic surgeon, as 68.8% and 57.7% would prefer to ask a family/friend or primary medical doctor, respectively. Television, magazines, newspapers, and the Internet share approximately a comparable amount of patient exposure (17.8%-34.6%) and have been successful in introducing a number of procedures to patients: breast augmentations, botulinum toxin injection, liposuction, facelifts, and blepharoplasties. Of these, liposuction, breast augmentation, and blepharoplasty were procedures that had been considered by those surveyed.

With regard to providers’ Web sites, those surveyed felt that board certification, training, and hospital affiliations were crucial in their search for a plastic surgeon. Web sites lacking information, listing high procedure prices, and reporting deaths were understandably found to deter potential patients. Interestingly, Google (66.8%) and WebMD (53.8%) were the two most popular domains that the surveyors selected as a Web resource of choice. Although those who wish to remain natural should not be coerced into undergoing procedures, plastic surgeons can address other deterrents such as a fear of operative risks and high costs for procedures. In other words, care can be taken to explain procedural risks and benefits while also providing financing options.

Discussion

The Web sites of plastic surgeons had the highest average overall ethical code scores compared to the other specialties studied. Although it should be highly encouraging to plastic surgeons that the specialty led its competitors in adherence to ethical standards with advertising, there is still room for progress in individual categories. Our results have demonstrated the areas of focus for continued improvement so that plastic surgeons may strive to be even closer to the ideal. It is through self-evaluation that the pursuit of excellence is made possible.

Plastic surgeons frequently practice in a private setting, which contributes to a highly individualistic nature. However, it is possible to craft one’s own message in Internet advertising while seeking guidance from the community via the ASPS and ASAPS Code of Ethics. Plastic surgeons can take advantage of WebGOLD and build a featured page on Plasticsurgery.org, which features a full suite of support and Web optimization for maximal exposure. This option also carries the benefit of internal monitoring and control, thereby benefiting all members of the Society while simultaneously improving the strength of the ASPS brand. Similar features are available through surgery.org, the ASAPS website, along with useful tools and information regarding practice promotion. On this site is a video presentation by Dr. Robert Singer, former president of ASAPS, discussing practice issues such as risk management, marketing, and ethics violations. Easily-accessible press releases provide current information on a variety of topics, ranging from revolutionary aesthetic techniques to patient cosmetic preferences. Educational DVDs, downloadable pamphlets, and other practice promoting guides can also be found at surgery.org.

Throughout Southern California, each region contained advertising practitioners of both high and low ethical code scores in a consistent distribution. Therefore, we conclude that no correlation exists between these scores and cosmetic provider geographical density. A focus on the quality of the Web sites of plastic surgeons in dense provider populations showed that they consistently had the highest scores. Plastic surgeons in areas of high competition seem to be reacting to competition by rising to the occasion, rather than stooping to the lowest common denominator.

There was a time when physician advertising was frowned upon and therefore unpopular. In 1982, the Supreme Court supported the 1979 Federal Trade Commission’s decision to no longer allow the AMA’s restriction on member advertising, as long as it was neither false nor misleading. Yet five years later, advertisements among physicians did not exceed 20%, a stark contrast to the 65% who currently advertise by means of the Internet (not including print, radio, and television); the slow uptake in advertising was likely due to the general consensus of physicians who disapproved of advertising and were pessimistic about its effects on the public.¹⁶

A study in 1987 reported that in the Yellow Pages (the most popular medium then), 12% of specialists were not specialty board-certified, despite having had ample opportunity to obtain board certification.¹⁷ The authors concluded that specialty advertising is potentially misleading to consumers and that the ABMS should consider options for limiting this possible misrepresentation. By the 1990s, the medical marketplace and the patient’s perception of healthcare had evolved irreversibly as patients took a more active interest in their health by seeking maximum information.¹⁸ Still, less than 1% of all physicians displayed ads in the Yellow Pages that included a physician’s experience.⁷ In the beginning of the 21st century, the booming popularity of the Internet seemed to reignite the question, “Are we promoting ourselves effectively and ethically when we advertise?”

Although national societies had championed plastic surgery very responsibly in serious media campaigns, the same cannot be said for all Web sites of aesthetic providers.¹⁹ Presently, a significant number of plastic surgeons still believe that advertising corrupts the physician-patient relationship and that marketing is inherently deceptive.²⁰ Although the Food and Drug Administration (FDA) monitors and markets the advertising media, the handful of employees assigned to that task are limited, and the number of advertisements to monitor is overwhelming. Ultimately, plastic surgeons must exert their control and maintain their own ethical standards to uphold their integrity as a profession. As the trend in physician advertising continues to shift from print to cyberspace, Dr. Singer urges plastic surgeons to take responsibility and “ensure compliance with [these] for Web marketing, whether or not these Web campaigns are created ‘in house’ or contracted through vendor services.”

Print advertising once dominated as the most popular means of advertising, but our survey results demonstrated that 60.6% of those surveyed would turn to the Internet as a primary source of physician and procedural information. Although the Yellow Pages and fashion magazines are still a major source of new patients referrals, patients are increasingly turning to Web sites as a primary resource for information about possible procedures and for scheduling consultations. A receptive American market and the increasing influx of cosmetic providers, as evidenced in a previous study,²¹ will continue to prompt growth in Internet advertising.

It would be interesting to evaluate the growth of Web site traffic being enjoyed by non–plastic surgery trained cosmetic providers. Several advertisement elements are highly important to the prospective patient population who was surveyed, including descriptions of a physician’s training, board certification, experience, and ethical values. However, the public’s level of knowledge regarding these terms is questionable. As Youn²² pointed out, due to the various board certifications and professional association memberships, most people cannot distinguish between these different “plastic surgeons.” Also of note, several individuals mentioned that medical school education determines the quality of surgical training; however, this is an erroneous notion, as proper surgical training is obtained in residencies and fellowships, not medical school.

Although the surveyed individuals in this study were aware of the importance of physician training backgrounds and board certification, there still exists a risk that the public may fall vulnerable to media overexposure and persuasive advertising.¹⁷ The objective of many television programs is to stimulate desire and entertain, such that they are often not an accurate representation of the physician’s credentials or skill set. In addition, some Web sites were found to have made statements such as, “Board certification will not substitute for experience, quality, and a good result.” It is not uncommon to see ads headlining promises to improve the quality of a person’s life; however, this type of appeal not only offers more than what the procedure was designed to do, but also likely attracts patients with a history of psychological disorders.²³ Regardless of the quality of the result, dissatisfied patients theoretically could litigate for compensation for any personal or physical disappointments they believe to have resulted from the procedure. In that way, unethical advertising could indirectly contribute to and increase litigation within the specialty.

There are a number of physician advertising practices that are deemed inappropriate, including payment in exchange for referral of patients or media coverage and exaggerated claims intended to create false expectations of favorable surgical results.²⁴ Promotional inclusion of preoperative and postoperative photographs intended to misrepresent results through different lighting, expressions, or manipulated poses is also unacceptable. Some also believe that adding stock images of patients who have never had a procedure performed by the advertising plastic surgeon is misleading and potentially contributes to patient skepticism.

Misrepresentation of credentials is another prevalent issue. In evaluating the 1307 Web sites in this study, many physicians were found to advertise themselves as being a “board-certified doctor” without specification of which particular ABMS board; this is in direct violation of the California law passed in 1999 that requires identification of the certifying board when advertising board certification.

Furthermore, in gathering data for this study, it was noted that descriptions of procedures with attractive language such as medical cosmetics and spas are commonly included in the Web sites of dermatologists, primary care physicians, and registered nurses, as possible attempts to minimize the invasiveness of liposuction and dermal filler techniques. Although inappropriate practices exist in the advertising realm, Dr. Singer paints the big picture well by advising plastic surgeons to “remember [that] the unsatisfied patient is a bigger problem than the competition. . . . [Plastic surgeons have] worked so hard getting where [they] are; why . . . throw it away by doing something inappropriate?” Plastic surgeons hold themselves to a high standard in training and board certification, and this should be reflected in the veracity and clarity of their communication with the public.²⁵

In short, it is important that the public have a facile means of finding physicians who are skilled and appropriate to serve patients’ cosmetic needs.²⁶ Dr. John Canady, former ASPS president, recommended that the plastic surgery community should not avoid advertising opportunities as long as the ASPS Code of Ethics is utilized.²⁷ “As technology improves and society continues to change, we’re all going to be faced with ethical and moral challenges,” Dr. James Wells, a previous ASPS president, has said. “When we make our choices based on what’s best for our patients and their welfare, the bottom line will ultimately take care of itself.”²⁷ Our results show not only that plastic surgeons seem to have taken this call to ethics seriously, but also that there is room to continue the progress toward maintaining an ethical “high ground” in the digital era.

Conclusions

Although our data evaluation of plastic surgeons’ Web site advertising shows that the specialty is demonstrates greater overall compliance with the ASAPS/ASPS Advertising Code of Ethics, they can continue to improve. With the large variety of cosmetic physicians offering the same procedures, maintaining open, honest, and forthright communication with the public is essential. Media can be used to better inform, empower, and gain the trust of patients by emphasizing the meaning of board certification, offering complete curriculum vitae, discussing the possible procedural risks, and including photos of actual patients.

Disclosures

The authors declared no conflicts of interests with respect to the authorship and/or publication of this article.

Funding

The authors received no financial support for the research and/or authorship of this article.

References