INTRODUCTION
An increasing number of professionals from other specialties have been practicing
techniques previously exclusive to plastic surgeons. Assisted by technological media,
they end up becoming a kind of “reference” for laypeople, who are unaware of the risks
of carrying out invasive procedures without due technical support. The plastic surgeon
who respects the ethical standards performing his medical advertising actions within
the legal norms adopted by the regulatory councils, 1 ends up losing credibility and suffering the consequences because he cannot follow
the growth of services provided on the internet, social media, and mobile apps2.
In this environment created by the emergence of new digital health technologies, many
paradigms are being broken. The opening to obtain further knowledge allows the plastic
surgeon to become familiar, versatile, and comfortable with social media, using them
for future commercial actions and growth in practice professional3. However, little is explored in the information regarding the use of medical applications
to monitor patients.
OBJECTIVE
This article aims to analyze the use of digital mobile applications by patients and
professionals to understand the importance and recognition of this type of technology
to provide more quality and safety in medical care, specifically for elective care
in the plastic surgery specialty.
METHODS
This is descriptive and retrospective research that carried out two analyses: (1)
of the conversations on an instant messaging application on the communication channel
for monitoring patients undergoing surgeries in a private clinic of the author, from
January to March 2019. (2) The use of digital technologies in plastic surgery, through
the analysis of a research questionnaire’s answers sent to professionals.
1st
Analysis:
During the period analyzed, 61 patients of both sexes, aged between 18 and 60, held
conversations through the application for three consecutive months.
On the day they scheduled the surgery, the patients received requests for preoperative
exams and a printed material containing guidelines for performing the procedure. The
material was also about post-operative care and the respective informed consent form
for the surgery. Besides, they became aware of the main means of contacting the medical
team, including the cell phone number available for permanent assistance, by voice
call, text messages, or by instant messaging application (WhatsApp®).
After undergoing surgical procedures, patients routinely received phone calls and/or
messages at the end of the day that they were discharged from the hospital and, subsequently,
as required by the case. The basic questions established by the assistant team involved
subjective analyzes of the general condition, such as pain, discomfort, difficulty
breathing, swelling, and appearance in the operated region, also emphasizing to the
patients the possibility of subsequent contact, through telephone calls or a mobile
messaging application. In any clinical or surgical manifestation that required medical
participation, the responsible professional was informed about taking the necessary
measures and determining the appropriate conduct.
• The variables analyzed in the conversations conducted through the instant messaging
application on the communication channel intended for monitoring patients were:
• Information about recovery after surgery;
• Reasons for contact through the messaging application;
• The average time elapsed between the surgery and the sending of messages by the patient.
• Subsequently, a satisfaction survey was carried out, which was to assess the care
provided by the team and the use of the mobile application in the patient’s postoperative
recovery.
Satisfaction survey:
a) Service of staff: (1) bad; (2) regular; (3) good; (4) great.
b) Use of the mobile application for postoperative recovery: (1) extremely useful; (2)
very useful; (3) indifferent; (4) unnecessary.
2nd
Analysis
Access links to the Google Forms platform were sent to 273 professionals in the specialty
of the southern region of Brazil in July and August 2019. The questionnaire contained
four questions:
• What are the most used means of communication for patient contact?
• What are the main problems faced in day-to-day practice?
• Which attitudes do you consider important to improve the performance of the office
or clinic?
• What are the means of communication currently used for professional dissemination?
The data obtained in the research with patients (1) and professionals (2) were analyzed
using the SPSS Statistics for Windows (version 16.0). Descriptive analysis of the
study variables was performed; for categorical variables, the absolute frequencies
(N) and relative frequencies (%) were calculated. The results were presented in the
form of graphs.
The analysis followed the principles of Helsinki (2000) and resolution 466/2012 of
the National Health Council that deals with the ethical and legal aspects of research
involving human beings in Brazil4.
RESULTS
zIn the sample obtained for the study (n = 61), an average of 7.4 conversations was
recorded using the messaging/patient/month application (minimum: 1; maximum: 18).
Among the messages received in the analyzed period, the main reason that led the patients
to use the message application BEFORE the surgery (n = 84) referred to the clarification
of doubts 29 (34.5%) and, shortly after that, consultations were scheduled 28 (33.3%),
other reasons are described in Figure 1.
Figure 1 - Reasons for spontaneous use of the messaging application by patients, BEFORE surgery
(n = 84).
Figure 1 - Reasons for spontaneous use of the messaging application by patients, BEFORE surgery
(n = 84).
Considering the monthly average of 122 conversations in the postoperative period,
86 (70.5%) were initiated by patients and 36 (29.5%) by the assistant team; its purpose
was to obtain information about recovery after surgery in addition to that received
by telephone contact. Among the messages of each established conversation, on average,
26 images and 13 patient audios were received each month.
It was found that the main reasons for conversations through the messaging application,
AFTER the surgery, were: scheduling a return appointment 21 (17.2%), clarifications
regarding pain 13 (10.6%), and about medications 12 (9, 8%). Other reasons are listed
in Figure 2.
Figure 2 - Main reasons for contact through the messaging application, AFTER surgery. Analysis
of the monthly average (n = 122). Note¹: Various (respiratory distress, physical activity,
fever, feeding, healing, drainage, stitch removal, intestinal dysfunction, use of
creams, itching, and sleeping position). Occurrence of each reason = 3 (2.4%) of cases.
Figure 2 - Main reasons for contact through the messaging application, AFTER surgery. Analysis
of the monthly average (n = 122). Note¹: Various (respiratory distress, physical activity,
fever, feeding, healing, drainage, stitch removal, intestinal dysfunction, use of
creams, itching, and sleeping position). Occurrence of each reason = 3 (2.4%) of cases.
In 59 (16.1%) of the total of 366 conversations per message carried out in the post-operative
period, images were requested to help clarify the initial doubt or concern. Thus,
it was possible to provide adequate guidance without the need to travel to the clinic.
In the analyzed period, there were 2 cases where the patient’s message through an
application resulted in an immediate referral for care at the hospital level, with
the previous diagnosis of hematoma, aided by the analysis of images sent by patients.
Regarding the time elapsed between the surgery and the sending of messages by the
patient, considering a monthly average, 57 (46.7%) of the conversations began before
the 15th postoperative day, with a higher prevalence on the 5th postoperative recovery
day.
After analyzing the messages, 57 of the 61 patients responded to the satisfaction
survey about the service and the use of the mobile application. All respondents considered
“optimal” the team assistance BEFORE the surgery, as well as the care AFTER surgery.
Besides, patients found it useful to communicate through a mobile application directly
with the clinic (Figure 3), contributing to their postoperative recovery, considering it as a differential
in care.
Figure 3 - Importance of direct communication with the clinic through the mobile application
(n = 57).
Figure 3 - Importance of direct communication with the clinic through the mobile application
(n = 57).
2nd
Analysis
Of the 273 questionnaires sent to professionals, 48 (21.8%) were answered fully,
thereby providing a 90% reliability index for the sample. In the responses, there
were 38 (49.3%) references to the messaging application (WhatsApp®), 27 (35%) to conventional
telephone, and only 2 (2.6%) to an application-specific to the clinic or office as
one of the main means of communication to facilitate contact with patients (Figure 4).
Figure 4 - Main means of communication used by professionals to contact patients. Based on the
total number of references (n = 77).
Figure 4 - Main means of communication used by professionals to contact patients. Based on the
total number of references (n = 77).
According to the professionals, the main problem that appears in the office’s daily
routine is the non-attendance/cancellations of appointments 22 (27%); secondly, competition
from non-specialist professionals 17 (21%); the reduction in prices for aesthetic
procedures was identified as the third problem to be faced 16 (20%). The remaining
problems are shown in Figure 5.
Figure 5 - Main problems faced by plastic surgeons in the office’s daily routine. Based on the
total number of references (n = 81).
Figure 5 - Main problems faced by plastic surgeons in the office’s daily routine. Based on the
total number of references (n = 81).
When professionals were asked about the attitudes, they would consider important to
improve the office or clinic’s performance, the use of social media, and finding measures
to reduce the rate of cancellation of consultations and surgeries received greater
emphasis, equivalently, representing 20 (24 %) of responses. Other attitudes are listed
in Figure 6.
Figure 6 - Attitudes considered important by Plastic Surgeons to improve the performance of the
office or clinic. Based on the total number of references (n = 82). Note²: Various
(offering online scheduling; being able to publish photos “before and after”; Stricter
Laws and Inspection for non-specialists).
Figure 6 - Attitudes considered important by Plastic Surgeons to improve the performance of the
office or clinic. Based on the total number of references (n = 82). Note²: Various
(offering online scheduling; being able to publish photos “before and after”; Stricter
Laws and Inspection for non-specialists).
Regarding the means of communication used for professional dissemination, Instagram®
was the most mentioned social network 27 (35%), followed by Facebook® 22 (29%). Also,
it was found that 12 of the (16%) surveyed do not advertise. Other means used can
be seen in Figure 7.
Figure 7 - Means of communication most used by plastic surgeons for professional dissemination.
Based on the total number of references (n = 77).
Figure 7 - Means of communication most used by plastic surgeons for professional dissemination.
Based on the total number of references (n = 77).
DISCUSSION
Besides the complete dedication and commitment of the professional to carry out his
work with quality, the classification of the result of a procedure or cosmetic surgery
is subject to the patient’s perception regarding the satisfaction of the treatment
as a whole, including the care received.
There were created printed materials to improve care, offer more significant support
to patients in preparation for surgery, and also generate prevention measures for
complications, which have been used for more than 12 years in the author’s private
clinic. Initially, contact with the patient was established by phone calls and text
messages (SMS). In 2015, the communication was made available via the instant messaging
application to clarify doubts and provide distance guidance.
Analyzing the exchanges of messages through the application during the study period,
an average number of 86 (70.5%) conversations initiated by the patient was recorded
each month, revealing that despite receiving standardized and comprehensive guidelines
before surgery, still needed support and assistance during the postoperative recovery
period. It is necessary to consider that most of the cases analyzed corresponded to
breast and body contour surgery, such as liposuction and abdominoplasty, which naturally
generate more doubts, discomfort, and insecurity in patients. In any case, it is evident
that in the absence of a digital communication facility, these patients would need
to be attended to in-person consultation, compromising the professional’s long time.
In the period observed, postoperative complications were diagnosed early through the
analysis of images sent by patients, which were adequately treated in a hospital environment.
This fact significantly reduced morbidity and prevented severe complications, as in
2 cases of hematoma, one after breast surgery with silicone prosthesis and another
after secondary abdominoplasty, respectively, on the 2nd and 3rd days after hospital
discharge.
In 2004, the importance of technology was considered to optimize care for plastic
surgery patients. The use of health information has increased relatively in the past
decade5. Since social media is introduced, plastic surgery has generally adopted them, especially
as a marketing, education, and communication tool6-10.
Most people who intend to perform surgery use the internet to do the research, even
before an appointment with the plastic surgeon6. It is estimated that more than 92% of the Brazilian population own or use a cell
phone. In addition to the basic use for calls and messages, these are now multifunctional
instruments that participate in all aspects of life, facilitating access and data
processing11. Some cell phone applications even allow patients to engage in their own medical
care. According to Noel et al., in 201712, using an application caused 20% of the patients not to call the plastic surgeon
or emergency service. No complications resulted from this decision.
The presence of digital technology as an essential factor in the development of communication
with the patient is of relative value in the education and decision process for surgery.
The use of applications has revolutionized access to information and applications
related to clinical evaluation cooperate to reduce the time for a therapeutic approach13. Nevertheless, some studies show that few applications are really useful for the
plastic surgeon to improve his daily work14-16. On the other hand, for a professional to develop his own application, several steps
are necessary, such as: explaining what the “patient” wants; perform tests of what
has been created; wait for adjustments and corrections and then manage the operation.
Most of the time, the results are lost hours, months of waiting, and years to start
working, in addition to the high cost to maintain and make the updates. Proof of these
barriers was that only 2 (4.1%) of the professionals surveyed invested in an exclusive
application for their clinic.
Over the past few years, plastic surgeons have faced several difficulties in the profession
and their offices’ management. Besides, the exponential increase in unqualified professionals
performing procedures previously considered to be plastic surgeons’ exclusive competence,
along with the high rate of patients who do not attend consultations or cancel last
minute procedures, causes considerable damage. It is necessary to keep the service
structure always available, without any financial compensation for the patient’s withdrawal.
For the plastic surgeon who, in addition to the health profession, is an entrepreneur
and manager of his career, it is understandable the preference for easier decisions
that bring better immediate results, as demonstrated in the choice of social media
(Instagram® and Facebook®) as a means of communication for the dissemination of your work. However, these are
also tools used by competitors, who, due to the greater availability of time and dedication
to these aspects, surpass most plastic surgeons. Not to mention that many publications
end up not adding value or producing a competitive market differential.
The proposal to use applications that facilitate appointments opens the possibility
of reducing the rate of absenteeism in consultations and the cancellation of surgeries,
which often bring considerable financial losses and time loss to the professional,
who makes available all of his physical structure and staff for the care of the patient.
He simply does not attend, especially when no financial compensation has been established
for this fact. In specific products among the digital resources available on the market,
it is possible to develop scheduling rules, proactively send information, control
the exams performed before the surgery, provide a “check-list” for the procedure and,
above all, do a more accurate follow-up of postoperative recovery. In the service
where the study was carried out, integrating the schedule, care protocols, preoperative
exam request routines, and postoperative guides through a mobile application has already
been instituted, improving patient care and helping the professional.
Medical consultation and surgical intervention in a judicious, ethical, and competent
manner are the basis of medicine and are irreplaceable in good medical practice. However,
the professional needs to be attentive to make quality differentials available, adding
services, convenience, tranquility, and security; thus, providing new perceptions
and experiences to the patient, which go beyond the technical capacity of practicing
an excellent surgical procedure, without complications and with low morbidity.
Among the population’s digital technologies, the cell phone stands out as the standard
device due to its practicality, lightness, and accessibility. It has the same numerous
functions that a computer offers and extensive use by the population.
Although there are still restrictions and some patients may find it difficult to use
applications on their cell phones, the expected benefits and the broad possibility
of creating new technological solutions support its validity to assist in health care.
CONCLUSION
The perception of the importance of digital technology in the assistance during medical
treatments, as well as the need to meet the requirements of patients and provide more
comprehensive monitoring in a practical, reliable, and safe way, provide the basis
to validate the use of mobile applications with specific resources in the care in
plastic surgery.
REFERENCES
1. Conselho Federal de Medicina (CFM). Manual de publicidade médica: resolução CFM nº
1.974/11. Conselho Federal de Medicina; Comissão Nacional de Divulgação de Assuntos
Médicos. Brasília (DF): CFM; 2011.
2. Janik PE, Charytonowicz M, Szczyt M, Miszczyk J. Internet and social media as a source
of information about plastic surgery: comparison between public and private sector,
a 2-center study. Plast Reconstr Surg Glob Open. 2019 Mar;7(3):e2127.
3. Cho MJ, Furnas HJ, Rohrich RJ. A primer on social media use by young plastic surgeons.
Plast Reconstr Surg. 2019 Mai;143(5):1533-9.
4. Ministério da Saúde (BR). Conselho Nacional de Saúde. Resolução nº 466, de 12 de dezembro
de 2012. Dispõe sobre diretrizes e normas regulamentadoras de pesquisas envolvendo
seres humanos. Diário Oficial da União, Brasília (DF), 13 jun. 2013.
5. Dickerson S, Reinhart AM, Feeley TH, Bidani R, Rich E, Garg VK, et al. Patient internet
use for health information at three urban primary care clinics. J Am Med Inform Assoc.
2004 Nov/Dez;11(6):499-504.
6. Montemurro P, Porcnik A, Hedén P, Otte M. The influence of social media and easily
accessible online information on the aesthetic plastic surgery practice: literature
review and our own experience. Aesthetic Plast Surg. 2015 Abr;39(2):270-7.
7. Vardanian AJ, Kusnezov N, Im DD, Lee JC, Jarrahy R. Social media use and impact on
plastic surgery practice. Plast Reconstr Surg. 2013;131:1184-93.
8. Gould DJ, Stevens WG, Nazarian S. A primer on social media for plastic surgeons: what
do I need to know about social media and how can it help my practice?. Aesthet Surg
J. 2017 Abr;37(5):614-9.
9. Mabvuure NT, Rodrigues J, Klimach S, Nduka C. A cross-sectional study of the presence
of United Kingdom (UK) plastic surgeons on social media. J Plast Reconstr Aesthet
Surg. 2014 Mar;67(3):362-7.
10. Sorice SC, Li AY, Gilstrap J, Canales FL, Furnas HJ. Social media and the plastic
surgery patient. Plast Reconstr Surg. 2017 Nov;140(5):1047-56.
11. Reusche R, Buchanan PJ, Kozlow JH, Vercler CJ. A systematic review of smartphone applications
for plastic surgery providers. Ann Plast Surg. 2016 Jan;77(1):6-12.
12. Noel W, Bosc R, Jabbour S, Kechichian E, Hersant B, Meningaud JP. Smartphone-based
patient education in plastic surgery. Ann Plast Surg. 2017 Dez;79(6):529-31.
13. Arruda FCF, Neves CGL, Prado M, Paulo PRS. Uso de aplicativos móveis em cirurgia plástica.
Rev Bras Cir Plást. 2015;30(1):101-4.
14. Kulendran M, Lim M, Laws G, Chow A, Nehme J, Darzi A, et al. Surgical smartphone applications
different platforms: their evolution, uses, and users. Surg Innov. 2014 Ago;21(4):427-40.
15. Venkataram A, Ellur S, Kujur AR, Joseph V. Smart apps for the smart plastic surgeon.
Indian J Plast Surg. 2015 Mai;48(1):66-74.
16. Mohan AT, Branford OA. iGuide to plastic surgery: iPhone apps, the plastic surgeon,
and the health care environment. Aesthet Surg J. 2012 Jul;32(5):653-8.
1. Plastic Surgery and Wellness Center, Private Clinic, Pato Branco, PR, Brazil.
Corresponding author: Vinicius Julio Camargo, Rua Tapir, Centro, Pato Branco, PR, Brazil. Zip Code: 85501-032. E-mail: viniciusjcamargo@yahoo.com.br
Article received: May 23, 2020.
Article accepted: July 19, 2020.
Conflicts of interest: none
