The Digitized Patient: What Can We Learn from Posted Patient Inquiries?

Introduction
-Tom Seery, Founder and CEO, RealSelf.com

I founded RealSelf more than 10 years ago because I believe that when you prioritize patient education, everybody wins. On RealSelf.com, this education plays out mostly in the form of patients’ direct interaction with the doctors on our platform. It’s the reason why nearly 10 million serious potential cosmetic surgery patients visit RealSelf.com each month to research treatments and doctors.

That volume of patients, and the quality and depth of their interactions on RealSelf.com, also afford us a robust data set that we can use to uncover insights into how people traverse the cosmetic surgery research process, what their key questions are, and how they’re interacting with doctors. We recently collaborated with Dr. Ram Kalus and his team to understand what patient questions on RealSelf tell us about gaps in the real life doctor-patient experience. Dr. Kalus discusses what that study found—and how doctors might use RealSelf as a tool to create more positive relationships with their patients, both online and off.

The Digitized Patient: What Can We Learn from Posted Patient Inquiries?
Ram Kalus MD, FACS

The plastic surgery and cosmetic medicine landscape continue to evolve as rapidly as technology itself. The pace of these changes challenge us all to stay current. This reality can be overwhelming at times to plastic surgeons and patients alike, and in this competitive marketplace, we can easily lose focus on our ultimate goals. First, providing the most advanced level of care in a compassionate, professional and ethical manner while ensuring maximal patient safety. And second, being successful in our respective practices, be they academic or private. Rather than allowing this accelerating pace of technological change to intimidate us, I would like to suggest that it may be possible to harness its power to our benefit, and to the benefit of our patients.

For many of us more senior plastic surgeons, the milestones in technological advancement can be linked to chapters of our own professional careers. As a microsurgical and maxillofacial surgery fellow at Dartmouth College in 1987, I recall that Dartmouth was the first campus in the United States to go “all Mac” shortly after the introduction of Apple’s MacIntosh SE (a vertical upright boxy desktop computer with a small black and white screen). When I accepted my first attending academic position three years later, the department provided me with a cellular phone about the size of a small toaster with a spiral coil cord handset, all in a nice faux leather pouch complete with a convenient shoulder strap. This was the very same year that the first commercially available digital cameras went on sale with a resolution of approximately three megapixels.

Today, most of our potential patients have the power of Google (which has become both a noun and a verb) at their fingertips (or voice command) 24/7. These aesthetic consumers can literally schedule a consultation with any one of us within seconds of having the notion to, not to mention a variety of apps allowing for virtual “pre-consultations”. This is nothing short of remarkable, yet also something we take entirely for granted today, as we all find ourselves in the “get-it-done-now” lifestyle to which we have all become accustomed.

The online postings by patients on RealSelf offer unparalleled insights into the minds and motivations of both our existing patients and potential future patients who are contemplating surgery or other treatments. The most concentrated data and insights are available at the website. RealSelf is a private company that launched in 2006, and has developed into a large-scale plastic surgery and cosmetic medicine resource for established and future patients, with approximately 10 million visitors per month¹. This compares with approximately 53,000 visitors per month to surgery.org (ASAPS)²; 83,000 visitors per month to Smart Beauty Guide, the public face of ASAPS³; and 400,000 visitors per month to plasticsurgery.org, ASPS’s website⁴. It is therefore evident that RealSelf has become a significant communication interface for the full spectrum of aesthetic surgery and cosmetic medicine and part of the practice landscape for many of us and our patients, both current and potential.

In 2008 the company introduced “Doctor Q&A” and has amassed over 1 million answers by board-certified or board-eligible plastic surgeons to questions posed by current or potential patients. The type of plastic surgery questions posed by visitors to RealSelf can be broken down into three primary types:

TABLE 1: Most Commonly Posted Inquiry Types on REALSELF

METHODS:
To help answer the question posed in the title of this article we approached the RealSelf team who, in turn, devised a survey to include all persons in the past three years who posted questions related to or matching the following query terms:

“Should I worry?”
“Is this an infection?”
“Heal” or “Healing”

This list produced 10,100 contacts, but over a three year period many of these individuals had either opted out of RealSelf emails or were no longer showing valid email addresses. Therefore, 5,606 emailed survey invitations were delivered. 112 started the survey, but only 93 passed the following qualification question:

“Within the last few years, you used the RealSelf “Ask a Doctor” feature. Did you ask a post-procedure question about whether what you were seeing or feeling was normal, or whether your recovery/healing was going as planned?”

RESULTS:
With regard to the three categories of questions in TABLE 1 above, we thought it would be especially useful to focus on Question Types 2 and 3 from post-operative patients to better understand why they are reaching out to RealSelf, rather than their own doctor’s office, with their concerns. The results appear in Table 1, with nearly half (45%) of respondents confirming that they had reached out to their doctor’s office before posing their question on RealSelf (FIG. 1). 34% had an appointment scheduled but did not want to wait. 29% had actually already seen or spoken with their doctor yet still decided to post their question on RealSelf, presumably for additional reassurance or confirmation. 11% “did not want to bother their doctor”.

FIGURE 1: POST-OPERATIVE PATIENT REASON(S) FOR POSTING THEIR QUESTION(S) ON REALSELF:

Among the nearly half of patients that had spoken to their doctor’s office (n=61) (FIG. 2), most wanted a second opinion (62%) or further reassurance (38%). 20% wanted to make sure their doctor hadn’t missed something, which would also arguably qualify as wanting “further reassurance”, but almost the same proportion said they didn’t agree with what they were told by their doctor or staff, yet did not want to share this with them (18%).

FIGURE 2: POST-OPERATIVE PATIENT REASON(S) FOR POSTING THEIR QUESTION(S) ON REALSELF AFTER SPEAKING WITH THEIR DOCTOR OR HIS/HER OFFICE STAFF:

Among the nearly half of patients that had spoken to their doctor’s office (n=61) (FIG. 2), most wanted a second opinion (62%) or further reassurance (38%). 20% wanted to make sure their doctor hadn’t missed something, which would also arguably qualify as wanting “further reassurance”, but almost the same proportion said they didn’t agree with what they were told by their doctor or staff, yet did not want to share this with them (18%).

One person wrote, “The doctor avoided me and wouldn’t answer my questions”. Another shared, “I posted my question on RealSelf because I didn’t want to wait for my doctor”. Of note was that almost half of the patients were posing their questions at least two weeks after surgery, and 25% were a month post-procedure.

DISCUSSION:
What conclusions can we draw from the data collected? Are there questions we as plastic surgeons should be trying to address, either individually, or as a specialty within the context of our societies?

First, we can all take comfort in knowing that new patient inquiries that fall into Question Type #1 in Table 1 reveal there is an ever growing pool of curious patients in the general population who might potentially convert to actual patients. That is, this data signals that there are more potential patients who might schedule a consultation, and hopefully a future scheduled surgery or other treatment(s) that we offer within our respective practices.

For example, with breast augmentation being the most commonly performed cosmetic surgical procedure both in the United States and worldwide5, the frequency of inquiries related to optimal breast implant size strongly suggests that women are yearning for information on how to best decide what type and size of implant is right for them. Other than offering our expert opinion in person in our own respective offices, perhaps we should be taking steps as a society to develop tools or create apps to better educate women to help them answer this question.

With regard to Question Type #2, what is concerning and deserves our attention, is that nearly half (45%) of patients who were concerned about their early post-operative course had already contacted their plastic surgeon’s office before posting their question(s) online. This is both curious and troubling, and is the essence of why I chose to author this article. Of this group of nearly half the patients who were queried, 62% indicated that they posted their question after speaking with the doctor or staff because they wanted a second opinion, and 38% wanted further reassurance. We can infer from this that somehow their questions or concerns were not fully or adequately addressed by their doctor or his or her staff.

We can conclude that for one reason or another, a disturbingly high percentage of patients found it easier or more desirable to post questions of concern regarding their healing or post-operative progress on RealSelf rather than contacting their own plastic surgeon directly. This can either mean that these patients find RealSelf to be more accessible than their doctor’s office, or for some other reason, was more patient friendly, or “user friendly” to borrow a term from the tech world. Here is such an example of an actual posted patient question:

“I had my surgery yesterday but I’m not supposed to see my doctor for two weeks. Someone please help.”

This suggests to us that it would perhaps be wise to re-evaluate systems and procedures that are in place in our own practices by asking ourselves the following questions:

1. What specific post-operative instructions have our patients received, and how was this information disseminated? Who in the office is responsible for providing this information? Is it done in person verbally, or with written instructions, or both?
2. How are patient calls handled, both during and after office hours? Is our front office staff welcoming and receptive, or rude and unhelpful? Do we have an answering service that has been properly educated to be appropriately responsive to our patients’ needs?
3. Does the patient coordinator or nurse behave in a welcoming, calming, and reassuring fashion to our patients, or are patients made to feel that they are a bother or a nuisance when contacting the office?

Finally, from Question Type #3 in Table 1, there are several sub-categories of inquiries that relate to being dissatisfied. Some are overtly hostile and litigious [“Was I botched? Can I sue my doctor?”], and often go unanswered. Yet most appear to be motivated by general concern, dissatisfaction, and disappointment, which are, thankfully, almost always addressed in an honest and forthright response by one or more participating plastic surgeons. These responses often end with the appropriate and correct recommendation that the patient go back to discuss her/his concerns with her/his plastic surgeon, or seek a second opinion from an experienced board-eligible or certified colleague.

But another question worth pondering by us as a professional group is whether or not participating in RealSelf makes sense. Clearly, being an active participant means that we are investing marketing dollars not only in a marketing vehicle that gives us exposure, but also one that calls upon us to offer our expertise without a specific expectation of a tangible return on our investment. In other words, we are voluntarily choosing to work for free by providing expert opinions without direct compensation. Why should we do this?

My own answer, as a practicing plastic surgeon for nearly 30 years, is that engaging with RealSelf gives me a unique insight into the patient’s perspective, in particular the issues that concern patients, the results they are seeking, and the questions they need answered. This active engagement makes me a more aware plastic surgeon when I meet a new patient for the first time, whether or not they found me via RealSelf.

CONCLUSION:
Online platforms such as RealSelf serve a threefold purpose. First, they are obviously a marketing tool for plastic surgeons by providing exposure. Second, there is little doubt that they also function as a powerful educational tool by tapping into the expertise of participating plastic surgeons. And third, they serve as a direct communication tool between physician and patient. While it is certainly not the role of any one of us to guide one another on if, when, or how to respond to RealSelf inquiries, I think we can conclude that, based on the data presented herein, reflecting on the content of such inquiries can potentially make us all better practitioners. Doing this can inspire us to reevaluate our own individual approaches to our practice. We are also challenged to always function in a “best practice” mode in caring for our patients and addressing their plastic surgery and cosmetic medicine needs, starting with the initial patient inquiry, continuing through their one year post-operative visit, and hopefully for many years thereafter.

REFERENCES:

1. Personal correspondence, Analytics Team, RealSelf.com.
2. Personal correspondence, American Society for Aesthetic Plastic Surgery, Inc.
3. Personal correspondence, American Society of Plastic Surgeons.
4. Personal correspondence, American Society of Plastic Surgeons.
5. American Society of Plastic Surgeons 2017 National Plastic Surgery Statistics

DISCLAIMER:
The author is a board certified plastic surgeon in private practice who participates with RealSelf as a subscriber and receives no compensation or financial remuneration, directly or indirectly, from RealSelf.  

ACKNOWLEDGMENT:
I would like to extend my appreciation to the analytics team at RealSelf for their assistance in developing and disseminating the questionnaire and data outcomes presented in this paper.