An Electronic Survey Study
David H. Burstein MD, Minas Constantindes MD, Anil R. Shah MD
Objective: Determine the impact of technology on facial plastic surgery
Methods: An electronic survey with 38 detailed questions was sent via email to 2274 American Academy of Facial Plastic Surgery Members. The survey inquired about use of email, practice websites, chat rooms, digital photography, morphing tools, and electronic schedulers. Respondents were stratified by years in practice, geography, and population of city practice is located in.
Results: 4.4% of members responded. In 2006, the use of email, practice websites, digital photography is common amongst all respondents irregardless of location or years in practice.
Conclusions: The use of a variety of technology and electronic media in facial plastic surgery is prevalent in 2006.
As technology improves and new applications emerge, physicians have an increasingly vast array of tools at their disposal. The potential benefits of such developments include improved efficiency, quality of care, and communication among physicians and between physicians and patients. However, with these technological advances come new legal and ethical considerations.
Facial plastic surgeons are particularly apt to become early adopters of technology. New technologies impacting facial plastic surgery include physician websites, chat rooms and discussion boards, digital photography and photo-imaging software, electronic schedulers, and electronic mail.
An electronic survey was conducted to gain perspective on the current use of technology and the Internet among facial plastic surgeons. The survey examined surgeon’s use of websites, email, the Internet in general, and new technology within the office. An attempt was also made to identify potential legal and ethical matters and see what steps, if any, were being taken to deal with these issues.
An electronic survey consisting of 41 questions were emailed as a hyperlink to all members of the American Academy of Facial Plastic and Reconstructive Surgery in July 2006. The survey was open for responses for a three month period and was sent to 2274 members of the Academy in total. The survey was created and data collected using Perseus Survey Solutions® (now part of Perseus/WebSurveyor), a company which provides online survey and results analysis programs. All questions were in a multiple choice or “choose from the following” format, and responses were entered and recorded online. The data analysis program permitted ‘filtering’ of results to distinguish different subsets of surveyers (i.e. Surgeons with over 20 years of experience versus 5 years of experience and use of websites)
Of the 2274 members who were sent a survey via email, 99 completed the online form during a three month period between July and October 2006, for a response rate of 4.4%. All percentages reported herein are rounded to the nearest whole number.
65 of the respondents are in private practice, while the rest have an academic affiliation. 40% practice in a major city, 32% in a medium-sized city, 26% are in a suburban environment, and 2% practice in a rural community. Thirty respondents have been in practice for less than five years, 33 have been practicing for 5-15 years, 19 for 16-25 years, and 17 for more than 25 years.
Practice websites are maintained by 83% of survey respondents. Of these, 16% have had a website for less than one year, 45% for 1-5 years, and 39% for more than 5 years. Of note, 88% of the respondents who have been in practice for more than 25 years maintain a website, as do 67% of those who have been in practice for less than 5 years. There is also little variation between respondents who practice in urban as opposed to suburban environments. 75% of those with a website report that less than 25% of their patients are attained as a result of their website, and half report that only about 25% of their patients have viewed the practice’s website prior to the first consultation. Still, 100% report that their website has generated positive feedback.
80% of respondents use their website as both a means of advertising and a means of informing patients about procedures and policies, and 86% say they use it to promote the image of their practice. When asked to select features that are included on their website, 82% of respondents report that their site includes personal biographical information, 76% include logistical information about the practice, 72% include educational information about procedures offered, 61% include a link to email the physician, 46% include a FAQ section, 37% include a photo album of surgical results, and 23% include clips of television and magazine appearances. To maximize exposure, 39% of those with websites either pay for search engine placement or utilize a search engine optimization company. Despite potential legal issues that may arise with medical websites, only 37% include a disclaimer about the use of information found on their site, and merely 10% have consulted an attorney regarding the content of their website.
Email is used to communicate with colleagues by 95% of respondents to this survey. 52% say they seldom or never communicate with existing patients via email, while 19% do so frequently. Similarly, 61% of respondents seldom or never communicate with new patients by email, while only 13% say they often do. 45% say they do answer questions or consult patients about medical issues over email; however, only 5% ask patients to sign consent forms to communicate in this mode. 45% of respondents use email to transmit patient-related data, and only 58% (of respondents) are sure they use a secure email exchange server. 33% say they are unsure.
Regarding use of the World Wide Web, 95% of respondents perform literature searches online, 82% read scientific articles, 93% obtain information about meetings and conferences, 78% search for data about medical products, 23% subscribe to newsgroups, 21% search for available jobs, and 20% participate in videoconferencing. While only 2% of respondents report participation in web-based discussion forums or chat rooms for facial plastic surgery, 22% report that they have patients who do utilize these venues.
All of our respondents use some form of photography for preoperative evaluation. Concerning its use, 88% use exclusively digital photography, 10% use both digital and 35mm photography, and only 2% use exclusively 35 mm photography. 63% of respondents use photo-imaging software for preoperative consultation. 65% use it for rhinoplasty, 38% for facelifts, 57% for chin augmentation, 25% for blepharoplasty, 28% for forehead lifts, 7% for Botox® injections, 13% for lip augmentation, 11% for fillers, 12% for facial resurfacing, and 31% for aging face surgery. 33% of respondents provide patients with a copy of the projected results, and of those who do, 86% include a disclaimer that the results are not guaranteed. Only 14% show patients images of possible complications.
In terms of office related technology, 32% use electronic patient charts, 84% use an electronic scheduling system, and 77% use medical billing software.
There were no major differences within any of the above categories based on years of experience or practice environment.
With the ever changing technological sector, new advances are constantly made that may be valuable to the practice of medicine, and facial plastic surgery is no exception. The incorporation of computers and technology into the office can improve efficiency and organization in a cost-effective manner. The use of websites, email, and the Internet has the potential to improve communication amongst physicians and between physicians and patients. Photography and photo-imaging are useful modalities to improve the quality of patient care and communication with patients. However, both legal and ethical concerns arise with the use of websites, internet chat rooms, and photo-imaging.
The use of practice websites is more prevalent in the field of plastic surgery than perhaps any other. The results of this survey indicate that it is the rare facial plastic surgeon who does not maintain such a website. Interestingly, older physicians who responded to our survey utilize websites as much, if not more, than younger physicians. One might expect that these advances would be embraced by younger, more technologically-inclined physicians, but this does not appear to be the case. Given the universally positive feedback that respondents have received concerning their websites, it is likely their use will continue to expand.
The utility of a website to a facial plastic surgery practice is manifold. Broadly speaking, websites can be used for informational and marketing purposes, and four out of five respondents say they use it for both. Websites are a very efficient way to provide existing and prospective patients with biographical information about the physician(s), logistical information about the practice, and educational information about the procedures offered. The majority of surgeons who responded to this survey include all these features on their websites. Shamsian and Southern note the importance of writing medical information on websites clearly, simply, and with graphic and multimedia enhancement so the average reader is able to understand and benefit from it.1 Invariably, there is an element of marketing within all websites, as they may represent the face of the practice. For this reason, it is important for the content and appearance of a website to accurately represent one’s personality, style, and philosophies.2 In fact, 86% of respondents use their website to promote the image of their practice. Many surgeons include photo albums which display their results, and some include images of magazine clippings and videos of television appearances to maximize their publicity. Carroll warns against false advertising on physician websites in an effort to attract patients. Specifically, information should be presented clearly and truthfully and should not be misleading in any way. Statements about patient satisfaction with a specific procedure or general services provided should be honest and verifiable and should not suggest a guarantee of any specific result.3 Of note, a significant proportion of respondents (39%) either pay for search engine placement or for a search engine optimization company. Both of these marketing techniques are used to increase the number of visitors to one’s website as opposed to those of competitors.2 It is likely that while most surgeons include educational information on their website, it is a distinct subset which maximizes the advertising capabilities of the Internet.
Despite the element of advertising inherent in all practice websites, the majority of respondents say they obtain only a small percentage of their new patients directly from their sites. In addition, most responded that only a small percentage of their patients even view their website prior to the initial consultation – a surprising result. There are two plausible explanations for this finding. First, it is possible – even likely – that many physicians are unaware of the extent to which patients research their doctors prior to making an appointment. A survey of patient use of the Internet for medical purposes would be interesting. Second, it is possible that this is an accurate estimation. The survey results indicate that the development of practice websites is a relatively recent phenomenon, as 61% have had a website for five years or less. Perhaps the majority of patients are still referred via the time honored “word of mouth” method. In either case, the number of patients who find their surgeon via the Web, or at least the number who will investigate their friend’s recommendation by visiting the physician’s website, is certain to increase in the coming years.
In their analysis of the medico legal aspects of imaging and internet communication, Koch and Chavez pose the question of whether a doctor can be held liable if a patient suffers harm as a result of relying on information published on the physician’s website. They conclude that the physician should be safe if the information is accurate, since there was no direct interaction between the two parties. However, they do recommend that physicians include a general disclaimer about the intended use of information on the site.4 In our study, only 37% say they have such a disclaimer on their website, and only 10% have consulted an attorney concerning the content of their site. Carroll’s article suggests that physicians include, among other precautions, a “terms and conditions of use” page that requires users to click their mouse and agree to the disclaimers indicated. This agreement should also contain a declaration of legal jurisdiction.3 Implementing these measures seems like an easy way to avoid a potential legal headache, but ensuring the accuracy of posted information is most important.
World Wide Web
In addition to maintaining websites of their own, the results of this survey indicate that facial plastic surgeons are using the World Wide Web for a variety of purposes. The majority use the Internet to perform literature searches (95%) and read scientific articles (82%). In a similar survey of plastic surgeons worldwide conducted in 2000, Koch et al reported that 76.6% used the WWW for literature searches and 60.2% read articles online.5 The data implies that these luxuries are becoming more popular, and this will only increase as even more journals become available online. In a review of 38 studies analyzing doctors’ use of the Internet between 1994-2004, Masters also noted that the most common uses of the Internet are to access journals and search medical databases, although the percentages quoted in that article are generally lower, perhaps due to the extended time period covered.6 Most respondents to this survey also go online to obtain information about meetings and conferences (93%) and to search for data about medical products (78%). In Koch’s survey, 60.4% went online for information about meetings, while 43.5% sought data about products.5 These increases are likely due to the increases in available information as well as the physician’s willingness to go online for it.
Only a small minority of surgeons who responded to the survey (2%) participate in web-based discussion boards or chat rooms, but 22% report that they have patients who utilize these venues. Koch reported that 11.5% of his respondents participated in discussion forums (or newsgroups) but that 67.6% would like to participate in one dedicated to plastic surgery.5 The reason for the discrepancy in these results is unclear (perhaps it relates to wording of the questions), but it is likely that greater than 2% of surgeons participate in some form of online discussion. Chat rooms have the potential to allow patients from various environments to communicate with each other in an anonymous fashion. This has the potential to encourage fruitful discussion between participants. A virtual meeting forum on the Internet is less intimidating than meeting face to face with one or several strangers. These sessions can facilitate the discussion of topics or asking of questions which patients may feel uncomfortable bringing up with their physicians. This venue also adds convenience, allowing patients to discuss issues wherever a personal computer and the Internet are accessible.
However, there are several theoretical pitfalls of chat rooms. An anonymous source, which may or may not be a physician, can misrepresent a surgeon’s work. This source may pretend to be a patient with a remarkable result and encourage patients to have surgery performed by a particular surgeon. The unknowing, trusting patient may then have surgery on this premise of misrepresentation. The source can also pretend to be a poor outcome in an attempt to steer patients away from a particular surgeon. Another concern with these modes of communication is the lack of accurate information. A patient who has had several operations and has read the Internet extensively is not a substitute for an informed surgeon who has performed the procedure and knows the limitations and realistic outcomes which can be achieved. Even a physician who “volunteers” to answer questions may have a motive to lure patients into their office rather than educate the chat room participants. Caveat emptor – ultimately, it is left to the patient to decide what information is accurate and to make an educated decision.
Despite the fact that few physicians from this survey admit to participating in these forums for facial plastic surgery, a significant percentage are aware that their patients do use them. Thus, it is important for physicians to understand how these forums work, who uses them, and what potential dangers exist. As use of the Internet becomes even more commonplace, it is only natural that more patients will utilize these online modes of communication.
Beyond chat rooms and discussion forums themselves, countless websites exist that offer uncensored medical information. An interesting study published in 2002 tested the accuracy of medical information available on the Internet by reviewing websites found by searching for the keyword “breast augmentation.” The authors determined that of the first 130 accessible and relevant sites, nearly 34% contained information which they deemed false or misleading. Even more contained exaggerations of the truth.7 This data can be easily extrapolated to facial plastic surgery procedures and shows how the Internet provides a breeding ground for misinformation. It is important for surgeons to be prepared for patients who have been exposed to this inaccurate information.
The advantages of email communication are obvious. It is fast, efficient, and permanent, and it permits the transmission of electronic documents very easily. One can imagine how this would translate into increased efficiency within a medical office. In addition, physicians are increasingly using email to organize and make arrangements for scientific meetings.8 In fact, 95% of our respondents indicate that they communicate with colleagues via email. This data suggests a slight increase in the use of email since the time of Koch’s survey, as 85.5% of respondents to that survey used email professionally and 82.5% used it for communication with colleagues.5 In his review, Masters found that a relatively small percentage of doctors use email to communicate with colleagues and patients (24% and 22%, respectively), but there was a trend over time showing an increase.6
In contrast, fewer surgeons than expected (less than half who responded to this survey) regularly communicate with either existing or new patients by email. As one might imagine, email may represent an easier option for answering patients’ questions than trying to reach someone over the telephone. It allows the physician to leave a message in a private mailbox that the patient can retrieve at his convenience. Though it may offer increased privacy from family members, email in general can not be considered a private mode of communication. When an email travels from a sender to its recipient, it must pass through several mail servers and routers. Most servers and internet providers store backup copies of messages sent and received, thus creating a virtual paper trail. At each point along its path through cyberspace, the message is vulnerable to eavesdropping by outside sources since most servers are inadequately protected and most messages are sent in plain (readable) text. To ensure privacy, emails must be encrypted, which means simply that the content of the message is translated into incomprehensible text that can be decrypted only by the appropriate recipient.9,10 Email is particularly vulnerable to privacy invasion in the office setting, where employers clearly proclaim their right to audit emails (often as a disclaimer at the bottom of every email). While a significant number (45%) of respondents to our survey say they transmit patient-related data over email (which is consistent with Koch’s report that 33.3% transmit patient-related data via email5), an alarming number (42%) say they either do not or are not sure whether they exchange email securely. These uncertainties make email a potential breeding ground for HIPAA violations.
Another alarming result is that many respondents (45%) answer medical questions or consult patients by email. Others2,8 have reported that they frequently receive emails from patients they have never met that contain photographs and descriptions of their problems. In addition to the privacy concerns mentioned previously, legal liability becomes an important issue here. Koch and Chavez4 point out that if a patient suffers harm as a result of advice received in a personal email from a physician, it is much easier to establish a cause of action because there is a direct link between the physician and patient. Carroll adds that direct online communication between a physician and an Internet user might qualify as the “practice of medicine” under some states’ laws. In order to avoid legal ramifications, physicians in these locales must adhere to the standard of medical care required by state law. Plastic surgeons who consult patients or answer direct medical questions via email should confer with an attorney and become familiar with their state’s laws regarding this issue.3 As Becker recommends, it is prudent to withhold medical advice until the patient presents for a consultation.
Concerning the use of office technology, most respondents use electronic scheduling devices (84%) and medical billing software (77%), while a smaller number have switched to electronic patient charts (32%).
Developments in photography and photo-imaging have the ability to improve the quality of patient care for plastic surgery patients. Better quality photographs and imaging software allow for more detailed preoperative analysis of facial anatomy and more accurate depictions of expected results. This should be used to improve communication between physicians and patients and help patients make more informed decisions regarding surgery.
All of our respondents use some form of photography. The great majority (88%) use exclusively digital photography, while a surprising number (10%) still employ 35 mm film in addition to digital. It is the rare plastic surgeon (2%) who still uses entirely 35 mm photography.
Only about 2/3 surgeons who responded to this survey utilize photo-imaging software for preoperative consultation. The most popular uses for it include rhinoplasty and chin augmentation, while its use for aging face procedures is also significant. The fact that some are using this software for minor procedures such as injections, fillers, and resurfacing indicates that it will probably become more prevalent as surgeons become more familiar will all its applications.
Some physicians have concerns that using photo-imaging to show patients projected results makes them more vulnerable to legal liability. Many have avoided giving patients copies of their projected results as a result of this fear. Koch and Chavez thoroughly explored this topic and concluded that surgeons face little danger as long as a few precautionary measures are taken. They state that courts would hesitate to rule that using imaging establishes a contract to achieve a particular result. They also point out that since imaging generally displays desirable results, it is very important to review prognosis and potential complications when obtaining informed consent. They recommend showing images of possible unfavorable outcomes, as well as including a disclaimer on all images that the results depicted are not guaranteed.4 That said, taking these precautionary measures should not encourage a surgeon to use photo-imaging to sell the procedure. The goal is to improve communication between the physician and patient. Results displayed with imaging should be realistic, if not understated, so that patients are in fact making informed decisions. In our survey, only one-third of those who replied provide patients with copies of their imaged results, and of those who do, 86% include a disclaimer that the results are not guaranteed. While obtaining informed consent is obviously necessary, very few show images of unexpected outcomes.
Two significant shortcomings of this survey are the sample size and the selection bias. The fact that only 99 surgeons (4.4%) responded limits the strength of any conclusions we are able to draw. More importantly, this survey was only sent out via email. Thus, there is a considerable selection bias for surgeons who utilize computers, email, and the Internet.
The main conclusions that can be drawn from the data are that the use of technology within all aspects of facial plastic surgery is growing. Most surgeons utilize websites to communicate with patients and to market their practice. Email is a popular means for communication amongst physicians, but its use to communicate with patients, though existent and growing, is less than expected. Physicians are using the Internet for several purposes, but they are not participating in chat rooms or discussion boards for facial plastic surgery. It is important to know about these forums, however, since patients do use them and their popularity may increase. The integration of websites, email, photography, photo-imaging, and other technologies into one’s office and practice is seen among physicians of all backgrounds and experience levels. It is not more prevalent among younger physicians, as one might expect. The survey results suggest that more experienced surgeons are willing and able to incorporate these rapidly advancing technologies into their practices.
Since there is certainly a significant portion of the plastic surgery patient population that does not read physician websites or communicate via email, physicians must not forget the value of the doctor-patient relationship. These advances are not intended as a substitute for but rather as a valuable complement to the more traditional modes of communication.
1. Shamsian N, Southern SJ. Plastic Surgery Web Sites: What Is the Quality of Information Currently Available? Plast Reconstr Surg. 2006;117:686.
2. Becker DG. Website for Rhinoplasty and Facial Plastic Surgery. Facial Plast Surg. 2006;22:70-74.
3. Carroll J. Legal Examination of Physician Advertising on the Internet. Facial Plast Surg. 2006;22:75-79.
4. Koch RJ, Chavez A. Medico legal Aspects of Imaging and Internet Communications. Facial Plast Surg. 1999;15:139-144.
5. Koch H, Dabernig J, Allert S, Puchinger M, Scharnagl E. Plastic Surgeons and the Internet: Results of a Worldwide Survey. Ann Plast Surg. 2002;49:466-471.
6. Masters K. For What purpose and reasons do doctors use the Internet: A systematic review. Int J Med Inform. 2006; doi:10.1016/j.ijmedinf.2006.10.002.
7. Jejurikar SS, Rovak JM, Kuzon Jr WM, Chung KC, Kotsis SV, Cederna PS. Evaluation of Plastic Surgery Information on the Internet. Ann Plast Surg. 2002;49:460-465.
8. Rohrich RJ. The Web and Your Cosmetic Surgery Practice. Plast Reconstr Surg. 2001;107:1253-1254.
9. Weiss N. E-mail consultation: clinical, financial, legal, and ethical implications. Surg Neurol. 2004;61:455-459.