During assessment of reviews, we identified reviews that contained both positive and negative dimensions (called “heterogeneous” reviews), which enabled us to infer relative importance of dimensions by means of the calculation of odds ratios. We identified 51 heterogeneous reviews of 1077 total reviews (4.7 percent), 37 of which were positive reviews and 14 of which were negative.
All computed odds ratios were found to be statistically significant at α = 0.05 (Table 4), confirming that the dimensions associate with positive and negative reviews. The largest odds ratios included 1932 for perceived skills of the surgeon, 1873 for aesthetic outcome, and 1121 for surgeon attentiveness. The lowest odds ratio was 96 for time spent with the patient. Among the negative Yelp reviews, 37 percent were from reviewers who did not receive surgery from the surgeon they were reviewing. Conversely, no positive reviews were attributed to patients who had a consultation but did not undergo breast augmentation.
Online reviews continue to play an increasing role in influencing consumer choice of surgeon, making it essential for plastic surgeons to understand the factors that may influence a patient to leave a positive or negative review. Our study was designed to help elucidate these factors for breast augmentation, one of the top two most commonly performed aesthetic operations.17 , 18
As is so often the case on the Internet, negative voices can be the loudest on review sites. Although the vast majority (87.5 percent) of reviews of plastic surgeons online were positive, the word count of negative reviews was higher than that of positive reviews. A dissatisfied patient will likely take up more screen real estate on a review site, and this may have real consequences for surgeons. Studies of movie and media sites have found that negative online reviews deter customers and decrease sales.22–24 Following up with patients who leave negative reviews, as Nathan et al. suggest, may help minimize damage to one’s reputation.25 However, publicly airing such discussion online is not advised because of Health Insurance Portability and Accountability Act of 1996 violation risks.26 Rather, a generic reply without exposing any patient-specific information may be an option in some cases.
Unfortunately, because of the Health Insurance Portability and Accountability Act of 1996, surgeons have little power in contesting online patient reviews, and this underscores the potentially unfair asymmetry of information presented on these review platforms. Online reviews are generated from self-selected respondents, and those with more extreme positive or negative feelings may be more likely to leave reviews than those whose feelings lie somewhere in between.14 Indeed, our results demonstrate the skewed bimodal distribution of one- and five-star reviews, with few moderate reviews in between—strong feelings elicit strong reactions, and these convert to voluntary acts of reviews online. That high word count associated with negative reviews suggests that patients have more to express when they are dissatisfied with their experience.
Among negative reviews, poor aesthetic outcome was most commonly attributed to asymmetry and implant malposition, but we also identified a recurrent theme of discordance between surgeon- and patient-perceived outcomes, where the surgeon felt that their work was well done but the patient was unhappy with their own appearance. Of course, the patient’s perspective of a poor outcome may not necessarily represent a technical failure of the operation. Patient perception of the quality of their result is likely related to preoperative counseling and expectations, actual technical result, and how the surgeon handles postoperative care.27–29 Several studies have demonstrated that patient and surgeon assessment of aesthetic outcomes often disagree.30–34 A patient’s misinterpretation of the aesthetic outcome—or discordant views between surgeon and patient—may lead to a patient (mis)perception that the surgeon is “failing to take responsibility.” This may also cause patients to feel that their surgeon is not listening, which was another top five reason for dissatisfaction. Thus, the study findings lend credence to the notion of establishing a strong foundation of reasonable expectations. Multiple prior studies have demonstrated accordingly that physicians with the best patient communication skills also had the highest patient ratings and satisfaction.35–37
Interestingly, although breast augmentation has often been lauded as a “commoditized” surgical procedure,38 we found that reasonable cost was the least commonly mentioned reason for patient satisfaction on all Web sites sampled in our study. Satisfied patients alluded to their provider’s competence and bedside manner far more than they did to price of the procedure. This is in accordance with findings of previous studies that found relative cost of procedures was the least important reason for patient satisfaction with their plastic surgeon.39 , 40 Domanski and Cavale, who evaluated Worth It ratings for popular procedures on RealSelf, likewise found that cost did not appear to impact the Worth It score.13 Price sensitivity among patients may be subject to variation, depending on the socioeconomic status of the population being sampled.41 However, the caveat to this is that patients may be hesitant to note in a public review that price significantly affected their choice.
Notably, 36.7 percent of negative Yelp reviews and 9.4 percent of negative Google reviews were written by patients who had only consultations but not surgery. Major themes among these reviews included “rudeness” and “curtness” of the surgeon, brevity of consultations, and the perception that the surgeon was “greedy.” These sentiments stopped the reviewers from proceeding with surgery but motivated them to leave negative reviews online. In contrast, no positive reviews were attributed to reviewers who did not undergo surgery. This highlights the importance of the presurgical consultation in protecting a surgeon’s aggregate rating: a bad consultation experience can lead to negative reviews, but a good consultation is only one step toward a positive one. Because Yelp allows patients who had even cursory interactions with a business to publish reviews, surgeons who want to protect their aggregate rating must consider the patient experience through all phases of the interaction, not only during and after surgery.
Our analysis of all reviews across all procedures and experiences garnered by plastic surgeons identified by our Web search further demonstrates differences across platforms and metropolitan areas. On the whole, reviews on Google were more favorable than those on Yelp (p < 0.01), and this relationship was also observed in each metropolitan area (Table 3). The difference was marked in Houston, where the average Google rating was 4.7 and the average Yelp rating was 3.8 despite 60 percent overlap in surgeons reviewed. The number of reviews per surgeon varied across metropolitan areas on both Google and Yelp independently (p = 0.03 for Google; p < 0.01 for Yelp) (Table 3). These observations suggest differences in user bases or biases across platforms. A nuanced, contextual interpretation of online ratings for a given surgeon should consider these underlying differences in volume and rating tendencies across locations and platforms.
Furthermore, our secondary analysis identified aesthetic outcome, perceived skills of the surgeon, and surgeon attentiveness as having the largest odds ratios, meaning that performance along these dimensions was most influential on patient satisfaction. We categorized these topics as critical traits for satisfaction (Table 6). We further identified rude office staff, little time spent with the surgeon, and experiencing a complication of surgery as negative dimensions that had relatively high rates of satisfaction (25, 22, and 21 percent, respectively). These were categorized as redeemable traits—negative dimensions that can be mitigated by other positive dimensions. The most common mitigating reason for a positive review was good aesthetic outcome; reviewers often expressed the sentiment that even though they encountered negative experiences, they ultimately left a positive review because they liked their aesthetic result. Other notable sentiments expressed in heterogeneous reviews included the following: leaving a positive review despite spending little time with the surgeon because of the perception that their surgeon was an expert with a high-volume practice, and leaving a positive review despite a surgical complication because their surgeon had proactive follow-up and demonstrated empathy through the healing or revision process.
We were specifically interested in whether poor aesthetic outcome could be overcome. Our data demonstrated that only 5.6 percent of reviews that mentioned a poor aesthetic outcome left a positive rating. Analysis of these reviews revealed that these patients ultimately left positive ratings because of realistic expectations about the possibility of a poor outcome and because of proactive follow-up by the surgeon. Although the rate of positive reviews among patients with poor aesthetic outcomes is too low to label this dimension “redeemable,” it does offer additional evidence that there are some possible actions a surgeon can take to protect his or her online reputation.
By means of sentiment analysis of other heterogeneous reviews, we identified three protective traits: good aesthetic outcome, proactive follow-up, and perceived expertise. Indeed, very few reviewers who had a good aesthetic outcome, who commented on their surgeon’s proactive follow-up, or who mentioned that their surgeon was highly skilled left negative reviews (0.9, 1.2, and 2.3 percent, respectively).
Patient reviews and satisfaction are naturally subjective. Our study is limited to what patients report, which may not necessarily capture all dimensions of their experience. Verification regarding authenticity of online patient reviews likewise remains challenging, and it is certainly possible that some reviews are inauthentic. However, of the 3833 Google reviews manually assessed for this study, there were only five instances in which a plastic surgeon responded and noted that the review was “fake” and not written by a patient of theirs. This does not exclude other fake reviews not flagged by the surgeon. Google, Yelp, and RealSelf all offer tools for reporting false reviews so that they can be removed. However, it remains unknown whether these tools are effective.42 In addition, Yelp has been embroiled in recurring controversies and claims regarding potential links between solicited advertising and favorable review treatment.43
On the contrary, review sites also enable patients to assess their experience with plastic surgery in real time, and thus may more accurately reflect satisfaction and dissatisfaction than surveys administered from physicians’ offices. Furthermore, individual surgeons may even avoid publishing their patient satisfaction ratings if they are subpar.13 However, there is less bias with online reviews that are easily accessible to the public. It is certainly possible that topography of online reviews has changed over the study interval. Perhaps as plastic surgeons have grasped the importance of these review sites, they have responded to what may have been initially a negative complaint platform and have transformed it into a conduit for positive shared experiences. Furthermore, the current study evaluates online reviews relevant only to primary breast augmentation. Additional studies are needed to evaluate online patient reviews applicable to other plastic surgery procedures.
In the rapidly changing marketplace of plastic surgery, online reviews are rapidly becoming the new word-of-mouth, with significant potential to influence patient referrals. In our study of 1077 breast augmentation reviews, the vast majority of reviews were positive, with significant variations by platform and geography. Good aesthetic outcome was both critical to and protective of a surgeon’s online rating—notably, it allowed conversion of some negative patient outcomes to positive reviews. Moreover, a reasonable minority of negative reviews were from patients who did not undergo surgery—underscoring the importance of a positive preoperative consultation in overall patient satisfaction. Cost did not appear to factor into positive or negative reviews. In summary, we present the first comprehensive analysis of the factors involved in online breast augmentation reviews. Nuanced understanding of these reviews may allow for development of concomitant surgeon strategies to improve patient satisfaction.
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Dr. David B. Sarwer is the Associate Dean for Research, Professor of Social and Behavioral Sciences, and Director of the Center for Obesity Research and Education, College of Public Health, Temple University, Philadelphia, Pa.
Even before the advent of Press-Ganey scores and other hospital-based assessments of patient satisfaction, plastic surgeons have been interested in quantifying the level of satisfaction of patients who have undergone cosmetic procedures. The earliest reports, from decades ago, repeatedly suggested that the vast majority of patients—often about 90 percent—reported directly to their treating surgeon that they were satisfied with a given procedure. Taken at face value, those observations are incredibly impressive. If given a second thought, however, the observations beg two questions. First, what percentage of patients would look their surgeon in the eye and state, “I’m not satisfied with my result”? Second, if that percentage was greater than 10 percent, what percentage of surgeons would share that observation with the larger plastic surgery community in a peer-reviewed publication? The answer to both questions is that direct assessment of patient satisfaction is subject to bias that calls into question the validity of the findings.
The study by Dorfman and colleagues represents a novel approach to investigating patient satisfaction with cosmetic breast augmentation. In a large and geographically diverse sample of patients who had provided online reviews of their breast augmentation experience on one of three well-known websites, the authors found that 87.5 percent of all reviews were positive. This result is consistent with those studies noted above. However, the use of reviews from these websites does not yield a comprehensive or random sample of patients who have undergone cosmetic breast augmentation. As a result, the finding is impacted by respondent bias. Nevertheless, the consistency of the findings across methodologies does provide support for the belief that many patients are quite satisfied with cosmetic breast augmentation and willing to share their positive experience with others.
In several respects, the negative reviews, while less frequent, are more informative to plastic surgeons and other members of the treatment team. Analysis of the negative comments suggests a couple of areas that even high-functioning, successful practices should target in an effort both to further improve overall patient experience and to minimize undesired patient experiences. Patients appear to be dissatisfied when patient-provider communication is poor, inconsistent, or nonexistent. While the communication style or “bedside manner” of the treating surgeon is paramount to a positive patient experience, the results suggest that interactions with other member of the treatment team can also impact patient experience to the negative or positive. All members of the treatment team are encouraged to communicate with patients in a manner that represents a respectful, warm, caring, and supportive health care environment.
The practice environment likely becomes of greatest importance when patients experience complications or unanticipated aesthetic outcomes. In my two decades as a psychologist working with plastic surgery patients both before and after surgery, I have observed that most patients minimize the risk of undesired outcomes. They approach surgery thinking positive thoughts (as they should) and probably assume that complications will happen to other patients. When a complication occurs, or they are dissatisfied with the aesthetic result, patients often report that they feel guilty, as if the negative result is a punishment for their vanity, and often describe the experience as if they were a character in a morality tale. In this situation, patients often benefit greatly from the support and compassion of the treating surgeon and team. If, however, they feel abandoned by the team—that the surgeon tells them their concerns are minimal, stops returning telephone calls, or refuses to see them, the negative feelings often evolve to anger that has the potential to serve as a catalyst to a malpractice suit.
As the authors note, the results of this study, along with those from previous investigations, suggest that positive patient-provider communication is of paramount importance in cosmetic surgery. This starts with the initial consultation, where the surgeon and patient should have explicit discussions about the patient’s expectations regarding the impact of the procedure on their physical appearance, body image, and quality of life. Establishing a strong, compassionate professional relationship at the onset will likely increase overall patient satisfaction rates and also provide an important foundation of support if an undesired outcome occurs.
Disclosure: Dr. Sarwer is currently a member of the Board of Directors of the American Board of Plastic Surgery and the Aesthetic Surgery Education and Research Foundation. He has consulting relationships with Allergan, BARONova, Medtronic, and Novo Nordisk.