Introduction
Consumer relations have changed over time and the means used to search for
products and services. The most efficient ways of promoting health services have
become online and offline media. In contrast, web technologies and mobile
technologies have increasingly influenced the health market in recent years,
increasing the impact of virtual media and social media on medical
professionals’ choice 1.
Features such as webinar, Slideshare, e-books, YouTube, Facebook,
Instagram, and Twitter are increasingly used
vehicles in the promotion and advertising of health services, and online
reviews, reviews, and ratings are an essential part of their decision making
process2. This new architecture
involving health data led to the creation and development of marketing
strategies focused exclusively on the medical area, generating ethical conflicts
and interfering in the doctor-patient relationship3.
With this emerged two antagonistic positions: those who see medicine as a
priesthood with its inviolable ethical precepts and those who see it as a
professional activity like all others, free to compete according to market
rules. Despite this duality concerning medical professionals’ positioning, a
marked change has been happening in the last 20 years, with an increase of more
than 450% in advertising expenses directed directly to the consumer of health
services, which means approximately 10 billion dollars spent annually on medical
marketing4.
In November 2018, the International Society of Aesthetic Plastic Surgery
(ISAPS)published data from 2017 on the number of plastic surgeries performed
worldwide. There were almost 11 million surgeries, of which the United States
held 14.5%. In second place is Brazil, with 1,466,245 plastic surgeries
performed, which corresponds to 13.6% of the total, followed by Japan, Mexico,
and Italy, adding up to these five countries 38.4% of all surgical procedures
performed the specialty in 2017. In addition to the Germany, Colombia, and
Thailand group, we have 45.3% of all plastic surgeries performed worldwide being
performed in these eight countries.
This significant number of surgeries performed in an extremely competitive market
raises some questions about the factors involved in surgeons’ choice and these
patients’ profile. It is known that personal indications (“word-of-mouth”) and
the professional’s reputation are considered quite significant criteria in the
choice of physician and that the doctor, concerned with the labor market, has
sought several alternatives to remain competitive6, but what is the true impact of the digital age in this “new”
consumer relationship?
objectives
This study aimed to describe the criteria for the plastic surgeon’s choice and
the sociodemographic characteristics and life habits of patients undergoing
plastic surgery in a single hospital in Goiânia - Goiás.
Methods
This is a prospective and descriptive study, conducted from June to November
2017, at the Hospital Premium, a private hospital in Goiânia - Goiás, which
specialized in performing plastic surgeries. All procedures were performed
exclusively by plastic surgeons specialist members of the Sociedade
Brasileira de Cirurgia Plástica (SBCP).
The present study included 501 patients submitted to predominantly cosmetic
plastic surgeries. Data were collected for six months (June to November 2017),
through interviews of patients with the nurse responsible for data collection,
after their hospital admission to perform the scheduled procedure.
All plastic surgeons who make up their clinical staff were invited to participate
in the study and, in order for their patients to be included in the sample, both
should agree in advance and sign the free and informed consent form (ICF).
The project was submitted for consideration in the research ethics committee
(CEP) of the Hospital das Clínicas (HC) of the Federal University of Goiás
(UFG), following the provisions of the resolution of the National Health Council
(CNS) 466/12 and in the operational standard of the National Health Council
(CNS) 001/13, obtaining its approval on October 20, 2016, with opinion number:
1,783,817 and certificate of presentation for ethical assessment (CAAE):
59601116.4.0000.5078.
All collected data were organized to increase the numerical order of identifying
their questionnaires and stored in an Excel database (Microsoft Excel 2010) for
its subsequent transfer to the SPSS-IBM version 22 software. The statistical
hypothesis and the association tests were tested.
Descriptive statistical analysis of quantitative variables was performed with
minimum and maximum values, means, medians, and standard deviation (SD). For
the
qualitative variables, their percentage values and relative and absolute
frequencies were presented.
The Chi-Square test performed the associations of categorical variables, and all
data were analyzed with a significance level (alpha) of 0.05(p<0.05) and a
95% confidence interval.
Results
The sample consisted of 501 patients who formed the database obtained by the
nurse responsible for its collection. The valid percentages for each variable
analyzed were considered.
Criteria for choosing the plastic surgeon:
- The number of plastic surgeons consulted presented the following
variation (Table 1):
Table 1 - Distribution regarding the number of plastic surgeons
consulted for the procedure.
Consulted |
n |
% |
A |
236 |
56.3 |
Two |
112 |
26.8 |
Three |
48 |
11.5 |
Four |
11 |
2.6 |
Five |
6 |
1.4 |
Six |
3 |
0.7 |
Seven |
0 |
0 |
Eight |
3 |
0.7 |
Total |
419 |
100 |
Table 1 - Distribution regarding the number of plastic surgeons
consulted for the procedure.
- The most common way to find the current plastic surgeon follows
below (Table 2):
Table 2 - Distribution as to how you found your current plastic
surgeon.
Means of encounter |
n |
% |
I was already a patient |
2 |
0.5 |
Another doctor indicated |
0 |
0 |
Friend/family member indicated |
396 |
96.4 |
Covenant catalog |
0 |
0 |
Magazine (health/beauty) |
0 |
0 |
Internet search |
9 |
2.2 |
Facebook Group |
1 |
0.2 |
WhatsApp Group |
2 |
0.5 |
Instagram Profile |
0 |
0 |
Other |
1 |
0.2 |
Total |
411 |
100 |
Table 2 - Distribution as to how you found your current plastic
surgeon.
- Among the most performed plastic surgeries before the current
procedure, we have (Table 3):
Table 3 - Distribution of plastic surgeries most performed
before the current procedure.
Surgery |
n |
% |
Liposuction |
19 |
12.7 |
Mamas |
101 |
67.3 |
Abdomen |
19 |
12.7 |
Glutes |
0 |
0 |
Hair transplantation |
0 |
0 |
Face |
1 |
0.7 |
Eyelids |
2 |
1.3 |
Nose |
7 |
4.6 |
Ears |
1 |
0.7 |
Other |
0 |
0 |
Total |
150 |
100 |
Table 3 - Distribution of plastic surgeries most performed
before the current procedure.
- Among the mammoplasties, the most performed was the increase in
silicone prosthesis (Table 4).
Table 4 - Distribution of mammoplasties by type.
Mammoplasty |
n |
% |
Increase |
114 |
75.9 |
Mastopexy |
25 |
16.8 |
Reduction |
11 |
7.3 |
Total |
150 |
100 |
Table 4 - Distribution of mammoplasties by type.
While 49.0% of patients reported that the procedure was performed with the same
surgeon, 51.0% performed the procedure with a surgeon different from their
previous surgeon (n=98).
Sociodemographic profile
Ages ranged from 15 to 77 years, whose mean and median were 35.31 and 34
years, respectively, with a standard deviation (SD) of 9.9 (n=501).
Regarding gender, 97.6% were female and 2.4% male (n=501). In the variable
skin color, 26.9% declared themselves white, 8.1% yellow, 64.7% brown and
0.3% black (n=356).
The level of education obtained was 2.1% with elementary school, 35.1% with
high school, and 62.8% with higher education, of which 2.2% had a master’s
degree, 2.2% with a doctorate, 8.7% master in business administration (MBA)
(n=433).
Regarding marital status, 35.7% were single, 0.5% had a stable union, 55.7%
were married, 6.9% divorced and 1.2% widowed (n=420).
Regarding pregnancies, 31.7% of the patients had never become pregnant, and
68.3% had previously become pregnant (n=429). Of the patients who became
pregnant, 30.3% had a single pregnancy, 51.0% had two pregnancies, 15.6% had
three pregnancies, and 3.1% had four pregnancies (n=294), with a mean of
pregnancies being 1.69 and median rate of 2.00 (SD=0.47).
In this sample, 86.2% of women never aborted, while 13.8% did, with an
average of 1.14 abortions and a median of 1.00 (SD = 0.35) (n = 420). The
percentage of patients who did not breastfeed was 44.7%. Of the 55.3% who
did, 1.9% were still breastfeeding at the time of surgery (n = 378).
Regarding future pregnancies, 30.6% of the patients who underwent plastic
surgery wanted a new pregnancy, and 69.4% did not (n = 369).
The average estimated monthly family income (in Reais) ranged from R$1,000.00
to R$50,000.00, with an average of R$7,341.69 and a median of R$6,000.00
(SD=5,871.20), and 83.7% of patients had an income of up to R$10,000.00 (ten
thousand reais), 14.9% of up to R$20,000.00 (twenty thousand reais), 0.7% of
up to R$30,000.00 (thirty thousand reais) and 0.7% up to R$50,000.00 (fifty
thousand reais) (n=307).
Anthropometric
Body mass (weight) ranged from 42 to 120 kg (Kg) (n=451), with an average of
63.99Kg and median of 63Kg (SD=9.95), and 43.5% of patients did not vary
weight in the 12 months before surgery, while 29.6% lost weight and 26.9%
gained weight. Losses ranged from 1 to 59Kg, with an average of 7.82Kg and a
median of 5.50Kg (SD=7.16). Gains ranged from one to 20Kg, with an average
of 5.33Kg and a median of 4.00Kg (SD=4.02).
While 49.0% of the patients intended to maintain their weight after surgery,
45.3% intended to lose, and only 5.7% intended to gain weight. This loss
expectation concerning the current weight ranged from 1 to 30Kg, with an
average of 5.77Kg and a median of 5.00Kg (SD=3.98). The gain ranged from two
to 6Kg, with an average of 3.78Kg and a median of 4.00Kg (SD=1.56).
The mean height was 162.93 centimeters (cm), with a median of 163.00cm
(SD=7.06) (n=448). The association of weight with height was able to provide
data on body mass index (BMI), whose mean was 24.10 and median 23.73
(SD=3.15). Regarding BMI, 7.6% of patients were classified as underweight,
56.7% as average weight, 31.6% overweight, and 4.1% as obese (n=446).
Lifestyle habits
While 44.3% of the patients reported not practicing any physical activity and
3.7% reported doing so less than once a week, 52.0% reported practicing
physical exercises more regularly than once a week. The mean training days
were 2.08, and the median was 3.00 (SD=0.99) (n=427).
The percentage of patients who never smoked was 97.3%, and 0.9% smoked in the
past, 1.4% were passive smokers, and 0.5% still actively smoked (n=437).
The ethyl habit was recorded by 34.7% of respondents, 23.5% drank less than
once a week, 10.1% once to twice a week, and 1.1% three to four times a
week, while 65.3% of the sample denied drinking alcohol (n=435).
No patient claimed to be a user of any drug, toxic or narcotic, and 4.7%
assumed they had already tried without becoming users, while 95.3% reported
having never had contact with any of these substances (n=429).
While 92.6% of patients denied regular use of medications, 7.4% reported
their use, among which 2.0% reported the consumption of natural formulas and
1.2% vitamin intake (n=244).
Discussion
Medical marketing has increased substantially over the past two decades, with
spending growing from $17.1 billion in 1997 to $29.9 billion in 2016. The
fastest increase was in direct advertising to the consumer of medicines and
services, which increased from $2.1 billion to $9.6 billion from 1997 to 2016.
When it comes exclusively to health services, this increase has been from $542
million to $2.9 billion over the past 20 years, with the increase in the number
of ads being 14,100 to $255,300, represented by the increase in advertising of
less expensive electronic media4
Even with this increase in virtual advertising, there is still little guidance
for young plastic surgeons who wish to use social media for professional
purposes, causing several behavioral doubts involving specialty members. This
has made many surgeons of different ages still resist using these media as a
marketing tool for fear of committing an ethical illicit or understanding that
this is a radical and unprofessional form of interaction with their patients
7.
Despite the controversy, medical websites and health care providers are becoming
increasingly marketing-oriented8, and
social media has been increasingly valued as communication tools to interact
with patients and educate the population. This appreciation is based on studies
showing that 65 percent of Americans and 90 percent of young adults use social
media7.
According to our study’s findings, the choices based on information available on
the Internet or social networks were 2.9% only, half of the percentage found
by
Araújo et al., in 20139, when considering
Internet, magazine or TV.
Despite the wide use of electronic media demonstrated by Cho et al. in 20197, they are a search tool still little used
concerning plastic surgery. These data are corroborated by Araújo et al.
(2013)9, in which personal indications
(from doctors, friends, or close relatives) for the choice of the plastic
surgeon were predominant. This type of marketing, also known as “word-of-mouth”
advertising, is supported by physicians’ opinion about its efficiency since
95.1% consider word-of-mouth advertising to be the best way to publicize their
office clinic10.
Data from our study also revealed that more than half (50.5%) of the patients
consulted only one plastic surgeon for the performance of their plastic
surgeries, agreeing with Araújo et al. (2013)9, whose work also revealed that the first consultation was
considered as one of the essential elements in the choice of the plastic
surgeon. Although people are becoming increasingly informed11, this demonstrates how much they still value the
empathy, trust, and attention of the professional during the consultation when
choosing their surgeon12.
This brings us to the fact that, despite the speed of transmission of information
and the rapid development of modern marketing in health, professional roles and
responsibilities should be seriously taken into account, especially when dealing
with social media in the field of medicine. Besides, it is essential that data
are not misused, always guarding patients’ privacy and confidentiality, so that
trust in the professional is not compromised1.
Another important aspect that should be considered is that, although medical
marketing increases in scope and scale, the professional should clarify the
clinical conditions and treatment options available. Doctors need to be cautious
to avoid behaviors that maximize profit at the expense of patients’ real needs.
Their ads’ content must be explicit and informative, respecting the profession’s
ethical precepts and safeguarding the doctor-patient relationship13. Because at the same time that
advertising and promotion are part of the strategy to maintain the relationship
with the target audience, their activities are regulated by ethical rules
established for the health market1.
Thus, promotional messages must show the truth without creating unrealistic
expectations, consistent and plausible communication, as the target audience
for
these ads is people who desire to be well. They are vulnerable beings who seek
to buy any service that appears to be following their desire to improve their
health status, even if that specific service is not good or suitable for
them1. Misleading advertisements with
promises of results should be repressed, which lead the patient to make the
wrong decisions based on incomplete or wrong information and unrealistic
expectations13.
About the patients’ sociodemographic characteristics, 35.3 year mean age is
supported by the literature9,14, as well as
the distribution regarding gender, with women predominance 5,9,14. Data related
to marital status also showed some similarities with other studies, with a
predominance of married people, followed by singles in this group of
patients9,14,15.
Concerning education, more than half had completed higher education, more than a
third high school, and a minority only elementary school, according to Araújo
et
al. (2013)9. In both studies, more than
three quarters of the sample had an estimated average household income of up
to
10,000 reais, followed by those earning 10 to 30,000 reais and a minority with
incomes higher than 30,000 reais, without exceeding 50,000 reais.
According to the survey of the ethnic-racial characteristics of the population,
from the Brazilian Institute of Geography and Statistics (IBGE), in 200816, when asked the color or race from an
open question (self-classification), 65% of the interviewees used one of the
five IBGE classification categories: white (49.0%), black (1.4%), brown (13.6%),
yellow (1.5%) and indigenous (0.4%), in addition to the terms “brunette” (21.7%,
including variants “light brunette” and “dark brunette”) and “black” (7.8%),
and
we found in the current sample a different classification regarding racial
composition, color item: 26.9% declared themselves white, 8.1% yellow, 64.7%
brown and 0.3% black.
Regarding the sociodemographic characteristics of the sample, taking data from
the Brazilian Institute of Geography and Statistics (IBGE), in 2002-200317, in the population aged 20 years or
older, the prevalence of overweight in the Midwest region was 2.4% for men and
6.2% for women, and obesity was 8.6% for men and 10.6% for women. Our sample
data revealed a higher overweight rate with a lower number of obese individuals,
corroborating the findings of Kaoutzanis et al., in 201818 and Gupta et al., in 201619.
Considering the life habits of the population studied, more than half of the
patients (52%) reported regular physical exercise, two-thirds (65.3%) denied
drinking alcohol, the vast majority denied the use of medicines (92.6%) and
smoking (97.3%). The total sample (100%) denied being a drug user, toxic or
narcotic.
Conclusion
This study’s conduction in a single center, whose scope is the performance of
plastic surgeries, provided support for a better understanding of the methods
of
choice most used by patients searching for a plastic surgeon, which were based
predominantly on the indication of friends and family. A reliable sample was
also produced to describe the sociodemographic characteristics of patients,
composed predominantly of young, married, brown adult women with higher
education level and belonging to the upper-middle class, physically active and
without addictions, demonstrating that this is the most common profile
concerning the search for plastic surgeries in our country.
The speed of social networks’ progress is opposed to the softness of its
regulation for medical use. The first constitutes a limiting factor regarding
the prospection of results for other populations outside this temporal context.
The second highlights the importance of good medical training regarding the use
of marketing according to current legislation to mitigate the potential harm
caused to patients, resulting from unethical and unregulated advertising. This
time distancing raises new studies to contemporize the impact of the Internet,
electronic media, and online reviews as criteria for choosing the plastic
surgeon and determining its influence on the decision-making process.
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1. Hospital Premium, Plastic Surgery, Goiânia,
GO, Brazil.
2. Hospital das Clínicas of the Federal
University of Goiás, Mastology, Goiânia, GO, Brazil.
3. Universidade Estadual de Ciências da Saúde e
Faculdade de Medicina CESMAC, Maceio, AL, Brazil.
Corresponding author:
Sylverson Porto Rassi Avenida T 4, 1445, Setor Bueno, Goiânia, GO,
Brazil. Zip Code: 74230-035 E-mail: drrassi@gmail.com
Article received: July 05, 2020.
Article accepted: January 10, 2021.
Conflicts of interest: none