In 1975, the American Medical Association (AMA) lifted the professional ban on physician advertising after a successful Federal Trade Commission suit.1 Since then, there has been a marked increase in the number of physicians marketing themselves directly to patients and consumers. With the pervasive nature of the Internet, never before has it been so easy and inexpensive to effectively communicate with a targeted population of people and influence their behavior. Few would dispute the role of advertising on consumer choices when used to sell products and services, change behavior, and educate consumers across all types of industries and professions. Thus, it is reasonable to hypothesize that the nature and content of a surgeon’s web presence could significantly affect patients’ decision-making and their impression of the orthopedic surgery profession.
There is a lack of consensus among physician organizations regarding physician advertising. For example, the American Association of Physicians and Surgeons (AAPS) takes an ethical stand on physician self-promotion. Their position states “The physician should not solicit patients. Professional reputation is the major source of patient referrals. The physician should be circumspect and restrained in dealing with the communication media, always avoiding self-aggrandizement.2” In contrast, the AMA has a less defined stance on physician self-promotion. With the exception of conflicts of interest and privacy guidelines, the AMA has few recommendations regarding the content of physician websites. The organization’s position states “There are no restrictions on advertising by physicians except those that can be specifically justified to protect the public from deceptive practices. …Nothing in this opinion is intended to discourage or to limit advertising and representations which are not false or deceptive.3” This guideline emphasizes accuracy of health-related information, but does not limit physician self-promotion or self-aggrandizement. The American Academy of Orthopaedic Surgeons (AAOS) holds a similar position. In their position statement on advertising by orthopedic surgeons, they encourage advertising and competition as “ethical and acceptable” as long as they are representing services in a “clear and accurate manner.”4 Furthermore, the AAOS also states that “An orthopaedic surgeon shall not use photographs, images, endorsements and/or statements in a false or misleading manner that communicate a degree of relief, safety, effectiveness, or benefits from orthopaedic care that are not representative of results attained by that orthopaedic surgeon.”4 The surgeon is responsible for his/her advertising materials and the content and claims therein, and is generally policed by peers through a complaint process with the AAOS.
Notably, up to 75% of Americans use the Internet for health-related information and this number is likely to increase.5Patients who utilize the Internet must choose from a vast array of search results for medical information from credible resources. Which sources are to be believed and relied upon? This depends on the health literacy among the general population. Inadequate health literacy is defined as “limited ability to obtain, process, and understand basic health information and services needed to make appropriate health decisions and follow instructions for treatment.”6 Patients have different levels of health literacy often unknown to even the most well-intentioned healthcare professional. It is often difficult to provide appropriate and meaningful information at a level that is most beneficial to the patient. It is estimated that 89 million people in the US have insufficient health literacy to understand treatments or preventive care.7 Certainly, with this information in mind, the orthopedic surgeon must consider his/her audience, and the potential for a fiduciary responsibility when preparing Internet content.
A tangible example of marketing results is the increasing popularity of robotic surgery over the last decade.8 Hospitals routinely advertise the availability of robotic surgery at their institution through various means, including roadside billboards. Despite limited evidence supporting a benefit of robotic surgery beyond less expensive conventional laparoscopic surgery, patients are increasingly seeking robotic surgery.8 With society’s increasing infatuation with technology, this is likely based on the presumption that robotic surgery is better and safer than conventional methods. It is likely that marketing pressure is at least partly responsible for the widespread adoption of robotic-assisted surgery and words used in marketing highlighting novelty have an important influence on patient preference.8
Orthopedic surgery, with its large proportion of elective surgeries, offers a unique venue to study differences in patient perceptions. Preoperative evaluations in orthopedics are often performed after an assessment of a surgeon’s reputation, which offers the patient an ability to choose their surgeon within their community.
We pondered how different promotional styles would affect potential patients’ perceptions. Would people believe that a self-promoting physician was more competent? Could fellow doctors “see through” the self-promotion of their peers? Based on the premise that advertising and self-promotion are undertaken because they are effective, we hypothesized that nonphysician patients perceive self-promoting orthopedic surgeons more favorably compared to members of the medical community.