One in Three Chance of Finding A Plastic Surgeon on Major Hospital Websites : Plastic and Reconstructive Surgery – Global Open

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Breast: Original Article

One in Three Chance of Finding A Plastic Surgeon on Major Hospital Websites

Singh, Nikhi P. MD, MBA*; Boyd, Carter J. MD, MBA; Aluri, Akshay BS; Kovac, Stefan BS; Mainali, Bipul BS; Girardi, Abdias BS; Duke, Riley BS; King, Timothy W. MD, PhD§,¶; de la Torre, Jorge MD, MSHA‖,**

Author Information
Plastic and Reconstructive Surgery - Global Open 11(1):p e4781, January 2023. | DOI: 10.1097/GOX.0000000000004781
  • Open
  • UNITED STATES

Abstract

Takeaways

Question: How are plastic surgeons represented on major hospital websites when searching for breast reconstruction?

Findings: The websites for the 20 most highly ranked hospitals by US News World and Reports were searched for common breast reconstruction terms. Plastic surgeons represented a third of search results, with other surgeons representing nearly half of results. On average, plastic surgeons appeared higher on search lists than nonplastic surgeons.

Meaning: Patients interested in breast reconstruction may encounter difficulty finding an appropriate plastic surgeon as inadequate search engines on hospital websites introduce inefficiencies for the entire health care system.

INTRODUCTION

Breast cancer is the most common malignancy in women, accounting for nearly 1 million new cases a year and representing 18% of total cancer burden in women. Patients afflicted by breast cancer may receive chemotherapy, radiation therapy, and/or surgery.1 It is well known that a woman’s breast is integral to her perception of femininity, motherhood, and self-image.2–4 Thus, reconstruction for these women is critical, as is adequate availability of plastic surgeons to perform these procedures. Specifically, Roughton et al5 have demonstrated that physical proximity to a plastic surgeon is an independent risk factor for patients undergoing breast reconstruction. Ultimate breast reconstructive modality depends on patient characteristics, need for future treatment, and patient preference.6

Breast reconstruction has traditionally been performed by plastic surgeons, who developed modalities, such as implant-based reconstruction, pedicled flaps, and free tissue transfer including perforator flaps.7 The majority of breast reconstructions performed in the United States (US) are implant-based.8 Several major catalysts such as the Women’s Health and Cancer Rights Act of 1998, the reintroduction of silicone implants in 2006, and the Breast Cancer Patient Education Act of 2015 expanded and enhanced care available to patients.9 As a result, the number of reconstructive breast procedures performed has increased by 355% between 1992 and 2015.9

As demand for breast reconstruction surged, the number of plastic surgeons practicing within the US has not increased as quickly. In an attempt to ensure all patients seeking breast reconstruction were cared for, plastic surgeons shared their knowledge of breast reconstruction with general surgeons through weekend crash courses and miniseries.10 This attempt to share knowledge outside of the specialty for the good of the patient may have created unintended consequences. Various studies report an increasing trend in the number of nonplastic surgeons performing breast reconstruction.11,12 While collaboration is a keystone of plastic surgery, it is concerning that breast reconstruction may one day be engulfed by nonplastic surgeons.

Health care in 2022 has become more and more integrated into online systems as patients can research hospital systems, look up diagnoses and treatments, and read physician reviews all online before seeing a physician. As such, the online presence and representation of physicians have become increasingly important. Within, we review the websites of the top 20 US hospital systems, according to the United States News World and Report (USNWR) hospital rankings, in an attempt to evaluate the plastic surgeon’s representation when searching for breast reconstruction.

METHODS

This study was institutional review board exempt as the project’s dataset consists of nonhuman data, which is publicly available. The USNWR ranks 20 academic centers annually across all care categories. Hospital programs that were ranked 1–20, including ties, on the USNWR in 2021 were considered for analysis in this study. Each hospital program’s official website was located and had a “find a doctor” feature. Researchers used this tool to search for “breast reconstruction,” “implant-based reconstruction,” “autologous breast reconstruction,” and “mastectomy.”

Information collected from search results included sex, whether or not they were allopathically trained, additional degrees, subspecialty, whether or not they attended a US medical school or US residency, their position in the search results, and h-index on Scopus at time of the search. H-index was used as a measure of the academic productivity and impact of listed physicians. Data were collected from October 18, 2021, to November 4, 2021. Independent sample t tests and descriptive analysis were conducted using Microsoft Excel (Seattle, Wash.).

RESULTS

Across all searches, a total of 1145 search results were obtained, averaging 286 (range 197 to 453) results per search term. When considering the gender distribution, the majority of suggested physicians were men (64%). The search term “implant-based reconstruction” suggested mostly male physicians (78%), while “mastectomy” revealed female physicians at a slight majority (52%) (Fig. 1). A total of 1000 allopathically trained (MD) physicians were present in the search results. Most attended medical school in the US (92%) and completed a US-based residency training program (98%).

F1
Fig. 1.:
Male physicians represent the majority of physician search results for implant-based reconstruction.

Plastic surgeons represented a minority (33%) of search results across all search terms. However, plastic surgeons were more likely to appear earlier on search results with an average search position of 17 (range, 1–195; SD, ±28) compared to nonplastic surgeons’ average position of 57 (range, 1–238; SD, ±59) (P < 0.001). Physicians listed under the search term “autologous breast reconstruction” had an h-index of 17.5 on average compared to those under “implant-based reconstruction” (9.3), “breast reconstruction” (9.6), and “mastectomy” (12.5).

Breast Reconstruction

The search term “breast reconstruction” generated search results for 18 of the institutions included in this study. Plastic surgeons did not represent the majority of search results with a collective representation of 45%. Four institutions suggested predominately nonplastic surgeons for this search term (Fig. 2). Other surgeons (33%) and nonsurgeons (15%) composed the remainder of search results (Fig. 3).

F2
Fig. 2.:
Percentage of plastic surgeons suggested for search term “breast reconstruction.”
F3
Fig. 3.:
Plastic surgeons represented less than half of physicians across all search terms and one-third of all search results.

Implant-based Reconstruction

“Implant-based reconstruction” searches yielded results for eight institutions, and plastic surgeons were not the predominant result, accounting for only 28% of resulting physician recommendations (Fig. 4). Most institutions suggested other surgeons over plastic surgeons (52%) (Fig. 3).

F4
Fig. 4.:
Percentage of plastic surgeons suggested for search query “implant-based reconstruction.”

Autologous Breast Reconstruction

When searching for the term “autologous breast reconstruction,” nine of the 20 institutions produced search results. Plastic surgeons represented less than a third of results listed (29%) (Fig. 5). Most of the suggested physicians were other surgeons (36%) (Fig. 3).

F5
Fig. 5.:
Percentage of plastic surgeons suggested for search phrase “autologous breast reconstruction.”

Mastectomy

The term “mastectomy” produced search results for 16 institutions and plastic surgeons represented only 17% of results (Fig. 3). The majority of institutions (56%) did not suggest any plastic surgeons at all (Fig. 6).

F6
Fig. 6.:
Percentage of plastic surgeons suggested for search term “mastectomy.”

DISCUSSION

With the increasing integration of the internet into health care, hospitals have adapted to allow for potential patients to find and evaluate physicians. A widely used tool to facilitate self-referral patterns is the “find a doctor” tool, which queries physicians and nonphysicians within the hospital’s system who match a procedure or disease process. With such tools, it is paramount that this feature appropriately displays results that enable and facilitate patients encountering appropriate physicians in an expedient manner.

Breast reconstruction encompasses several procedures that various medical specialties now perform. Plastic surgeons traditionally have performed breast reconstruction and are best equipped to drive the management of these patients, as comprehensive training in breast reconstruction is integral to graduating from integrated or independent plastic surgery residencies.13 We found that plastic surgeons represented only 33% of search results across all search terms for breast reconstruction. This is further exacerbated by the irregularity with which plastic surgeons populate breast reconstruction search results. Across all included institutions, there was a high variation in the appearance of plastic surgeons in search results. The search term “breast reconstruction” yielded search results in which less than half (45%) of the suggested physicians were plastic surgeons (Fig. 2). This is surprising given plastic surgery’s historic role in breast reconstruction. While there is significant value in working across specialties to ensure the highest level of care for patients, it appears that hospital website search systems unnecessarily convolute the physician discovery process for prospective patients.14 Ineffectively and inappropriately advertising physicians to perform breast reconstruction is detrimental to patients, plastic surgeons, and health care systems.

The majority of head and neck reconstruction is now performed by nonplastic surgeons, primarily otolaryngologists, who learned these procedures from plastic surgeons. While it has been demonstrated that plastic surgeons have superior outcomes in head and neck reconstruction when compared to otolaryngologists, oncologic otolaryngologists controlling the referral patterns have shifted this landscape.15,16 Such transformations could also occur in other areas of plastic surgery, including breast reconstruction. Continued advocacy for plastic surgeons and collaboration with oncologic breast surgeons are critical for maintaining plastic surgery’s integral role in breast reconstruction.

It is notable that the search term “mastectomy” was included in this analysis. While plastic surgeons do not traditionally perform oncologic breast surgery, all plastic surgeons hold foundational training in this area.13,17 There has been discussion of combining oncologic and plastic breast surgery. While plastic surgeons are appropriately equipped to solely perform oncoplastic breast surgery, separation of oncologic and reconstructive portions of breast cancer care helps prevent conflicts of interest between removing all oncologic diseases and optimizing aesthetic reconstructive results.10,18–20 As the number of plastic surgeons offering gender-affirming mastectomies continues to rise, inclusion of plastic surgeons in mastectomy search results is important for patients seeking this operation.21 It is not surprising that the h-index of physicians listed under the term “autologous breast reconstruction” has a higher h-index than those under other search terms, as patients undergoing such procedures are likely to be cared for at large medical centers, which typically emphasize and have support for research for academic surgeons.

The gender gap in the surgical workforce is well documented.22,23 In our sample, 41% of suggested physicians were female; however, the search term “mastectomy” did suggest a higher proportion of women to men. Despite higher than ever female representation in surgery, our data unfortunately confirm the still-persistent gender gap, even at the highest-ranked medical centers.24 Diversity of representation among surgeons is equally as critical a factor as any toward optimizing patient outcomes. Diverse teams at academic centers can promote the collaborative exchange of ideas, and previous studies have demonstrated that some patients prefer female surgeons surrounding sensitive topics, such as breast reconstruction.25,26 As such, both patients and plastic surgery as a profession would be better served by more equal representation.

Our data also demonstrate considerable variability in website user interface and search engine performance among top-ranking academic medical centers. For example, one institution’s “find a doctor” tool offered 99 search results related to “breast reconstruction,” while another institution’s search produced just one physician recommendation. While a breadth of information is valuable at times, an overabundance or underabundance during a presumable preliminary search to “find a doctor” should not be a hallmark feature of these tools. Moreover, our data reveal a diverse group of nonplastic surgeon specialties being recommended including orthopedic surgeons, obstetricians/gynecologists, nonsurgeons, diagnosticians, and internists. While plastic surgeons did appear higher on search lists than nonplastic surgeons in this study, only a third of breast reconstruction procedures were populated with plastic surgeon results, potentially mitigating this advantage in search position. Overwhelming and potentially misguiding patients is detrimental to their care. Consequently, we suggest that plastic surgeons work alongside their hospital systems’ information technology departments to ensure their services are both easily accessed and optimally presented to the appropriate patient populations. Previous studies have also raised this concern in surgical oncology, general surgery, and endocrine surgery.27–29

This study has limitations. We utilized the top 20 ranked hospital systems in an attempt to represent all hospitals across the US; however, our conclusions are inherently not generalizable to individual hospitals or regions. In addition, there are uncontrollable differences in each hospital search engine, such as identical searches providing different sets of information from one day to the next. Similarly, some hospital websites shifted the order of search results randomly. Physicians’ ranking information was not extracted for these hospital systems. While the term “implant-based reconstruction” is common vernacular for plastic surgeons, it may have been unspecific to capture physicians performing implant-based breast reconstruction. Finally, USNWR does not recognize plastic surgery or reconstructive surgery as a distinct care category, and as such, the selection of hospital systems included in this study is subject to selection bias.

CONCLUSIONS

Plastic surgeons represented nearly a third of all search results for common breast reconstruction search terms. This inadequate exposure emphasizes the importance of continued political advocacy as well as partnering with hospital information technology departments. The inconsistency of online search tools we observed emphasizes a need to optimize this tool. Medical centers should standardize efficient methodologies to augment search algorithms in displaying plastic surgeons as the most relevant and qualified surgeons for breast reconstruction.

REFERENCES

1. McPherson K, Steel CM, Dixon JM. ABC of breast diseases. Breast cancer-epidemiology, risk factors, and genetics. BMJ. 2000;321:624–628.
2. Hungr C, Sanchez-Varela V, Bober SL. Self-image and sexuality issues among young women with breast cancer: practical recommendations. Rev Invest Clin. 2017;69:114–122.
3. Prates ACL, Freitas-Junior R, Prates MFO, et al. Influence of body image in women undergoing treatment for breast cancer. Rev Bras Ginecol Obstet. 2017;39:175–183.
4. Huber C, Ramnarace T, McCaffrey R. Sexuality and intimacy issues facing women with breast cancer. Oncol Nurs Forum. 2006;33:1163–1167.
5. Roughton MC, DiEgidio P, Zhou L, et al. Distance to a plastic surgeon and type of insurance plan are independently predictive of postmastectomy breast reconstruction. Plast Reconstr Surg. 2016;138:203e–211e.
6. Lee GK, Sheckter CC. Breast reconstruction following breast cancer treatment-2018. JAMA. 2018;320:1277–1278.
7. Losken A, Jurkiewicz MJ. History of breast reconstruction. Breast Dis. 2002;16:3–9.
8. Albornoz CR, Bach PB, Mehrara BJ, et al. A paradigm shift in U.S. Breast reconstruction: increasing implant rates. Plast Reconstr Surg. 2013;131:15–23.
9. Ellsworth WA, Hill DA, Abu-Ghname A, et al. The impact of political advocacy on the plastic surgeon: a data-driven analysis. Plast Reconstr Surg. 2021;147:1039–1049.
10. Hermes PJJ, Losee J, Meumeister M, et al. ASPS President’s Panel: our role in the future of breast surgery: do we have one? Presented at Plastic Surgery the Meeting 2021, Atlanta, GA.
11. Chao AH. Safe and efficient implant-based breast reconstruction. Plast Reconstr Surg Glob Open. 2020;8:e3134.
12. Awan BA, Samargandi OA, Aldaqal SM, et al. The attitude and perception of breast reconstruction by general surgeons in Saudi Arabia. Ann Saudi Med. 2013;33:559–565.
13. ACGME. Operative Minimums Effective July 1, 2014 Review Committee for Plastic Surgery 2.
14. Blankensteijn LL, Crystal DT, Egeler SA, et al. The influence of surgical specialty on oncoplastic breast reconstruction. Plast Reconstr Surg Glob Open. 2019;7:e2248.
15. Drinane JJ, Drinane J, Nair L, et al. Head and neck reconstruction: does surgical specialty affect complication rates? J Reconstr Microsurg. 2019;35:516–521.
16. Lee ZH, Daar DA, Jacobson AS, et al. The decline of head and neck reconstruction in plastic surgery: where do we go from here? Plast Reconstr Surg. 2020;145:467e–468e.
17. Lopez CD, Bluebond-Langner R, Houssock CA, et al. Plastic and reconstructive surgeons’ knowledge and comfort of contralateral prophylactic mastectomy: a survey of the American Society of Plastic Surgeons. Front Oncol. 2019;8:647.
18. Macmillan RD, McCulley SJ. Oncoplastic breast surgery: what, when and for whom? Curr Breast Cancer Rep. 2016;8:112–117.
19. Chatterjee A, Dayicioglu D, Khakpour N, et al. Oncoplastic surgery: keeping it simple with 5 essential volume displacement techniques for breast conservation in a patient with moderate- to large-sized breasts. Cancer Control. 2017;24:1073274817729043.
20. Wang T, McGrath J, Wolff B, et al. The oncoplastic movement among general breast surgeons: will plastic surgery lose the turf war over breast reconstruction? Presented at American Association of Plastic Surgeons Meeting, April 2012, San Diego, CA. 2012.
21. Rifkin WJ, Robinson IS, Kloer C, et al. Gender-affirming mastectomy: comparison of periareolar and double incision patterns. Plast Reconstr Surg Glob Open. 2022;10:e4356.
22. Morris M, Chen H, Heslin MJ, et al. A structured compensation plan improves but does not erase the sex pay gap in surgery. Ann Surg. 2018;268:442–448.
23. Zhuge Y, Kaufman J, Simeone DM, et al. Is there still a glass ceiling for women in academic surgery? Ann Surg. 2011;253:637–643.
24. Pories SE, Turner PL, Greenberg CC, et al. Leadership in American surgery: women are rising to the top. Ann Surg. 2019;269:199–205.
25. Nolen HA, Moore JX, Rodgers JB, et al. Patient preference for physician gender in the emergency department. Yale J Biol Med. 2016;89:131–142.
26. Fink M, Klein K, Sayers K, et al. Objective data reveals gender preferences for patients’ primary care physician. J Prim Care Community Health. 2020;11:2150132720967221.
27. Gentry Z, Chen H, Fazendin J. Finding a cancer surgeon: how hospital websites make this difficult for their patients. Am J Surg. 2020;221:431–432.
28. Gentry ZL, Ananthasekar S, Yeatts M, et al. Can patients find an Endocrine Surgeon? How hospital websites hide the expertise of these medical professionals. Am J Surg. 2021;221:101–105.
29. Gentry ZL, Ananthasekar S, Chen H, et al. Finding a general surgeon: self-referral in the digital era. Am Surg. 2022;88:177–180.
Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.