Determining factors in choosing a plastic surgeon

Introduction: This study aims to understand the factors that determine the choice of a plastic surgeon from the patient’s perspective. This is a pilot project, which should be broadened and deepened by other studies. Method: A survey was devised in the form of a questionnaire with 22 multiple choice questions. The average response time was 8 minutes. The questions addressed various aspects, such as the recommendation, training, and accreditation of the surgeon; perception of the first consultation; and the clinic. There was no possibility of identifying the patient or surgeon; hence, anonymity was guaranteed. Results: The response rate was 86.66%. The majority (92.22%) of the respondents were female, with a mean age of 35 years. Most had completed secondary and higher education, with an average monthly family income of R$ 2,000 to 10,000. Almost 40% did not know the accreditation of the surgeon chosen and 33.7% did not know the length of training the surgeon had undergone. The majority (81.6%) believed they had paid an average amount for their surgery and half did not research the surgeon’s online profile. The majority (67%) had not undergone any previous plastic surgery. A list of 10 items in descending order of importance was presented. Conclusions: The determining factors for the choice of the plastic surgeon in this sample, in descending order were: 1) Recommendation, 2) Accreditation, and 3) First consultation. Price was not the most important factor and online presence was one of the last items cited. A significant proportion of respondents did not know either the accreditation level or the length of training of their surgeon.


INTRODUCTION
In the past, the choice of a physician was made solely and exclusively by recommendation or fame.The advent of the internet, and especially of social media, has made the spread of information more rapid and accessible to all.These are methods widely used by the population in the selection of a professional to perform a surgery or treatment.
Plastic surgeons spend approximately 7% of their time in career development and marketing and some spend up to $350,000 annually for this purpose.It would therefore be worthwhile to uncover the criteria used by patients in choosing a surgeon to make marketing directed, more efficient, and thus, more effective in this competitive setting 1 .
Brazil currently has around 6000 plastic surgeons and, according to a demographic study by the Brazilian Society of Plastic Surgery (SBCP), in some cities the plastic surgeon: inhabitant ratio reaches 1: 6347.These figures are alarming and justify this study.
One hundred and twenty surveys were distributed in six different clinics in the city of Curitiba, PR, 20 in each clinic.Of these, 104 were answered completely and included in the study, which lasted 4 months (September to December 2017).Incomplete surveys were excluded from the sample.
A spreadsheet with all the responses was prepared in the Excel platform and statistical evaluation with cross-checking of some data was performed.Graphs of the most relevant data were constructed to facilitate analysis.The statistical evaluation was performed by a professional.
Statistical analysis was performed with quantitative variables described as mean, median, minimum, and maximum values.Qualitative variables were presented as frequencies and percentages.The Chi-square test was used to evaluate the association between two qualitative variables.The Kruskal-Wallis non-parametric test was used to compare different classifications of a variable, in relation to the quantitative variables.
To compare the different scenarios according to the scores obtained by the patients, the non-parametric Friedman test was used.P-values <0.05 were considered to be statistically significant.The data were analyzed using the IBM SPSS Statistics v.20 software.

Description of the sample
The majority of respondents were females (92.2%), with an average age of 35.6 years.Almost half (47.1%) were married, and 40.7% and 12.5% were single and divorced, respectively.Their schooling is detailed in Table 1 below.Some data considered fundamental for the choice of surgeon, such as accreditation, training time, total price of surgery, and online presence, are detailed in Figures 1 to 4.    The average monthly family income was mostly between 2,000 and 10,000 Reais (69%) (Reais: the official currency of Brazil), followed by up to 2000 Reais (13.6%), and 10 to 30 thousand Reais (13.6%).Only 3.9% earned more than 30 thousand Reais.
Tables 2 and 3 describe the duration of the first consultation and the method by which the surgeon was chosen.
Half of the patients (50.5%) had consulted with only one plastic surgeon before choosing their surgeon, 34.7% consulted with two surgeons, and 13.9% with three to six surgeons.Only 1% consulted between seven and 10 surgeons.
Most of the patients had undergone no prior plastic surgery, as shown in Figure 5.
The descending order of the first and second criteria defined for the choice of plastic surgeon is detailed in Figures 6 and 7.
The p value was not significant (p-value was >0.05) in the following relationships: (a) Degree of instruction × accreditation of the surgeon; (b) Degree of instruction × search of online presentation of the surgeon are related; (c) Degree of instruction × online presentation of the surgeon are related; (d) Average family income × form of payment; (e) Average family income × search of online presentation are related.
Only the cases that evaluated all the scenarios were taken into account in this analysis.Thus, we tested the null hypothesis of equal scores for all scenarios versus the alternative hypothesis of at least one scenario with a different score from the others.
The scenarios created were evaluated by scores 1 (unlikely to choose) to 6 (very likely to choose), and those with the highest scores were scenarios 1 and 3 (3.8),followed by scenario 4 (3.5), and finally 2 (3.1).The details of the scenarios are set out in Annex 1.
Given the rejection of the null hypothesis, the scenarios were compared in a pairwise manner.The p values for these comparisons are presented in Table 4.

DISCUSSION
The market for plastic surgery and non-invasive procedures is one of the most competitive worldwide, and even more so in Brazil, where the number of plastic surgeons surpasses several important markets, including China, South Korea, Japan, Russia, India, and Mexico 2 .
According to ISAPS, the recent economic crisis has led to a decrease in the number of plastic surgeries in Brazil in 2015.In 2011, 905,124 surgeries were recorded; in 2014, it was 1,343,293, while in 2015, this reduced to 1,224,300.In 2016, there was a resumption (1,450,020) 2-6 .(otorhinolaryngologists, ophthalmologists, mastologists, general surgeons, and others) makes it even harder for patients to differentiate between these professionals 7 .Few studies have sought to identify the factors that influence patients in choosing a plastic surgeon and, in Brazil; there has been no previous study in this direction.This first study can serve as a basis for other, more detailed and extensive studies with larger sample sizes.
In other published studies, some have used an online survey and others written questionnaires to be completed.Generally, online surveys (through a link via e-mail) have a response rate of around 26% 8 .In two studies with plastic surgeons, the online survey had an above average response rate (40.45% and 70.5%).The increased response rate of the latter was probably because personal interviews were conducted with those who did not respond to the e-mail 9,10 .
Questionnaires can be tedious to answer; however, a response rate of 86.66% was obtained in this pilot project (104 complete responses from 120 questionnaires), which can be considered high in comparison to other studies 11 .Other studies have not reported the response rate to be compared, only the total number of answers.
Our study was performed only in plastic surgery clinics, while one previous study was performed in clinics of other specialties (family practice, internal medicine, and pediatrics) 12 .This could lead to a bias, since patients who have already decided to undergo an operation can provide more precise answers.Another study used crowdsourcing for this assessment, in individuals who had no concrete plans to undergo plastic surgery but were screened by the question "Do you one day plan to have this surgery?".Those who provided a negative response were excluded from the study 11 .The sample from this study may also not provide accurate answers as patients who have already chosen their surgeon and are in the middle of the process to operate.
One interesting study evaluated the difference made by the gender of the surgeon, male or female, to the choice made.Nearly half had no gender preference for their surgeon and 26% preferred female surgeons, especially in intimate and breast surgeries 14 .This factor was not evaluated in our study.Another showed that there was no preference for the sex, age, or race of an orthopedic surgeon 15 .
The vast majority of patients surveyed were female (92.2%), similar to other studies 1,12,13,16 .The mean age of the patients was 35.6 years, similar to the sample of Galanis et al. 12 , Marsidi et al. 13 , and Sanan et al. 16 ; Conversely, non-invasive procedures (botulinum toxin, fillers, and laser treatments) displayed a progressive increase: 542,090 in 2011, 715,212 in 2014, and 1,099,945 in 2015, with a slight decline in 2016 (1,074,995).The probable reason for this decline may be the recent influx of non-medical professionals (dentists, biomedical, pharmaceutical, and beauticians) performing these procedures.
The approximate number of plastic surgeons in Brazil is 6083, according to the last demographic study of the SBCP.However, the advent of other medical specialties performing plastic surgeries    11 .Regarding schooling, there was a predominance of complete secondary education (40.4%) and higher (38.5%), in agreement with Wu et al. 11 , Sanan et al. 16 , Shah et al. 17 , and Waltzman et al. 1 .The study of Marsidi et al. 13 reported only 8.7% of participants with complete higher education.
Our sample had a predominance of monthly family income between R$ 2,000 to 10,000 (69%), 13.6% with income between R$ 10,000 and 30,000, and only 3.9% above R$ 30,000.According to the IBGE (table below), the majority fit in classes C and D, with a lower in classes A and B (17.5%), almost the same as that in class E (13.6%) 18 .
These results differ from the sample data of Galanis et al. 12 , Marsidi et al. 13 , and Sanan et al. 16 , which had participants with income above the national average, but approached that of the sample populations of Wu et al. 11 and Shah et al. 17 .This can be explained by the fact that the three authors above used surveys with patients who had already undergone plastic surgeries, had a strong interest in the subject, or were still in the middle of the process.On the other hand, the latter two authors used online research platforms (crowdsourcing and SurveyMonkey) with a random population.Galanis et al. 12 , Marsidi et al. 13 , Sanan et al. 16 , Wu et al. 11 e Shah et al. 17 .
The data of our study also show that, despite a significantly lower monthly family income than in sample populations from other countries, Brazilian patients are interested in having plastic surgery or make a great effort to do so.
The significant growth of doctors who claim to be "experts" in the area of plastic surgery (aesthetic medicine, cosmetic surgery, etc.), through the creation of societies which are not recognized by the CFM, as well as the invasion of other specialties (mastologists, oncologists, ophthalmologists, otorhinolaryngologists, gynecologists, and general surgeons) in areas not yet recognized by the CFM (oncoplastic surgery, plastic eye surgery, facial plastic surgery, etc.) in accordance with the resolution of CFM No. 2.149/2016 (published in the D.O.U. of August 3, 2016, Section I, p. 99), leave people confused about the appropriate specialist to perform this type of surgery 19 .
Nearly 40% of respondents (37.9%) could not identify the accreditation of the surgeon chosen, 26.2% stated that the surgeon was a Specialist Member or a Full Member of the Brazilian Society of Plastic Surgery, and 7.8% responded that the surgeon was a member of the Brazilian Society of Aesthetic Medicine.This corroborates the findings of Shah et al. 17 , in which a similar percentage of patients did not know if a physician is required to have the title of specialist to perform plastic surgery.
The length of a surgeon's training or career is often perceived as an advantage, as if experience is necessarily an attribute to be valued.However, this view may be overvalued by the doctors themselves, regardless of the patients' attitudes.In our sample, 33.7% did not know how long a career the surgeon had had, demonstrating that this characteristic was not among the most important in the choice of a surgeon, as demonstrated by other studies 1,11 .On the other hand, three studies have demonstrated that number of years of experience is among the most important factors 13,15,17,20 .
The vast majority (87.6%) of the respondents stated that the price of their surgery was average, 10.7% above average, and only 4.9% below average.No specific value was defined, since we evaluated patients undergoing several types of surgeries, which would give a wide range of costs.It can also be questioned what is an "average" or "above average" value.Perhaps a separate study for each type of surgery would provide more accurate results in this respect.
The cost of a surgery has never been considered the main point in making a choice in any previous studies, usually ranking 4th place or lower in order of importance 1,11,13,17 .In one study, the offer of discount coupons in the marketing material for a plastic surgeon had a negative effect on the interviewees 16 .Galanis et al. 12 did not evaluate cost, but the fears of patients who refused to have plastic surgeries included poor results, postoperative recovery, and price.
More than half (67%) of the responders had not had any plastic surgery previously, corroborating data from Galanis et al. 12 and in contrast to Waltzman et al. 1 and Sanan et al. 16 , in which the majority had undergone some plastic surgery in the past.The last two authors surveyed different populations: one surveyed within a plastic surgery clinic and the second performed an online survey with a population selected by postal code.Shah et al. 17 reported that 72% had undergone surgical procedures in the past but did not specify whether they were plastic surgeries.
The online presence of the surgeon was also studied.More than half (54%) of respondents stated that they had not done online search and 28% said that the surgeon had a comprehensive website and social media with good ratings.Within the order of importance, this item was one of the last mentioned by the sample surveyed, as identified by Marsidi et al. 13 .
Wu et al. 11 evaluated pre and post-surgery photographs and testimonies as well as other items, which could be equivalent to an online presence, since these data are only found on websites and social media.This recent study (2017) demonstrated that these items (photographs and testimonials) were the two most important items in choosing a surgeon in four different groups with patients of different ages.The photos were even more important for the group of patients with an interest in breast augmentation, that is, on average younger patients.Perhaps it is a current trend that this factor is becoming increasingly important 11,20 .
The recommendation of a physician, relative, or friend was one of the most important factors observed in our study, with 37.9% of respondents ranking this item number one in order of importance.This was also demonstrated in other studies 1,13,20 .
A systematic review identified the reputation of the surgeon as one of the most recurring items in the choice of some specialties (oncology, cardiovascular, orthopedic, and plastic surgery), however, there was no consensus on what comprises "reputation".It may involve the recommendation of a physician, friend, or relative or the expertise (type of training, years of experience, the number of cases operated).Another author reported that reputation could be an advantage over new "experts" of unrecognized areas. 12,20he first consultation was also evaluated in our study and was one of the most important factors in choosing the surgeon (3rd place).A systematic review confirmed that some authors indicated that surgeons with empathy and compassion who were caring, reliable, and good listeners were the most chosen by patients.All these characteristics may or may not be perceived in the first consultation 20 .
In our study, 47.5% of responders reported that their first consultation lasted between 30 minutes and 1 hour and nearly 60% said that the surgeon chosen was very helpful and answered all their questions.This is a point to be carefully noted and can make a difference in a very competitive market, such as that in Brazil.
The crossing of some data characteristics showed a trend towards knowledge of the surgeon's training time and the degree of instruction, that is, patients with a higher level of education were better acquainted with the training time of the chosen surgeon.However, other crosses were not statistically significant (degree of instruction × surgeon title, degree of instruction × online presentation search, degree of instruction × online presentation search, and average family income × online presentation search).
This was not found in any of the previous studies.Only one author related the degree of instruction with the title of the surgeon and, curiously, found that those who had a lower level of education believed that a surgeon should be appropriately accredited and trained to legally market himself/herself as a plastic surgeon, while the highest educated believed that accreditation in plastic surgery was necessary to perform surgeries that improve an individual's appearance 17 .
Four scenarios were created for evaluation by the responders, in which the accreditation of the surgeon, distance from the clinic, price of surgery, training time, form of payment, online presence, and recommendation varied.The scenarios with the best scores (most likely to operate with this surgeon) had surgeons who were members of the SBCP (Full Member or Specialist), with the office 15 minutes away, average price or above, more than 10 years training, payment of up to 12 installments, variable online presentation, and the recommendation of a trusted physician or friend.These scenarios were used in other studies1, but with assessment through a conjoint analysis, which unfortunately was not possible in our study.

Limitations
The sample size of this study was small and cannot be considered representative of the general population because the study was performed in a specific city (with a different culture and socioeconomic conditions than other similar cities).The fact that the patients surveyed were already in the process of having a plastic surgery may also lead to bias.Not everyone has this desire for several reasons.
The six clinics studied had different profiles, taking into account the different social classes.However, the sample that answered the survey mainly belonged to classes C and D. For unknown reasons, patients from classes A and B had a lower response rate.The geographical and socioeconomic limitations of this study could be resolved with a larger sample size and the inclusion of other localities.
A conjoint statistical analysis could also be of great value to understand the weight of each item in this choice of surgeon (trade off), but we were unable to find experts who could perform this type of assessment.

CONCLUSIONS
The factors that determine the choice of a plastic surgeon are numerous and may depend on the population studied and their variables.In our sample, the most important factors are shown in order of importance: recommendation by a physician, relative, or friend, accreditation of the surgeon, and first consultation in the top rankings.Price did not figure among the main influences.Interestingly, the online presentation of the surgeon was one of the lowest ranked factors in order of importance.

Figure 1 .
Figure 1.Accreditation of the chosen surgeon.

Figure 2 .
Figure 2. Training time of the chosen surgeon.

Figure 3 .
Figure 3.Total price of the surgery.

Figure 4 .
Figure 4. Online presence of the chosen surgeon.

Figure 6 .
Figure 6.List of the first criterion defined for the choice of the plastic surgeon.

Figure 7 .
Figure 7. List of the second criterion defined for the choice of the plastic surgeon.

Table 2 .
Duration of the first consultation with the chosen surgeon.

Table 3 .
Recommendation of the chosen surgeon.

Table 4 .
Comparison of the scenarios presented.Waltzman et al. 1 reported a mean age of 51 years.Another study had 3 groups of surgeries that had different age ranges, but also with a predominance of the female sex

CHARACTERISTICS OF THE FIRST CONSULTATION WITH THE SURGEON THAT YOU HAVE CHOSEN TO PERFORM YOUR PLASTIC SURGERY 8
5. Total price of surgery a.Much cheaper than the average b.Cheaper than the average c.Within the average d.Above average e.Well above average 6.Form of payment (cash, check, or credit card) a. Cash b.Up to 5 installments without interest c. 5 to 10 installments with interest d. 10 to 36 installments times with interest 7. Online presentation: a. Comprehensive website with detailed information and no social media presence b.Comprehensive website with detailed information and with social media presenting good reviews c.Modest website with little information and no social media presence d.Modest website with little information and with social networks presenting good reviews e.Not researched anything online .At the first consultation the surgeon was: a. Disinterested, without answering my questions b.Attentive, but responded briefly c.Attentive, explained the whole procedure to me d.Very attentive, explained the procedure to me and showed pictures/photos