Commentary
Commentary on: What Do Patients Want?
Technical Quality Versus Functional
Quality: A Literature Review for Plastic
Surgeons
Aesthetic Surgery Journal
32(6) 762­–766
© 2012 The American Society for
Aesthetic Plastic Surgery, Inc.
Reprints and permission:
http://www​.sagepub.com/
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DOI: 10.1177/1090820X12452726
www.aestheticsurgeryjournal.com
Felmont F. Eaves III, MD, FACS
Ms Smith, your patient of many years, is beaming as you
walk into the examination room. After a brief exchange of
pleasantries, she seamlessly transitions into a request for
removal of some obviously benign skin lesions. As she
talks, you struggle to listen, mesmerized by the bizarre
face addressing you. A lateral sweep, tethered ear lobes,
inexplicable scar placement, and malpositioned fat grafts
seem to be only the start. “Oh, you’ve noticed I finally got
that face-lift we’ve been discussing for years,” she exclaims
through plethoric, distorted lips. “Isn’t it great?” She
drones about the work of her “cosmetic surgeon, Dr
Wannabee,” how nice the staff was, and the great price
she was given (“Thousands less than you quoted me!”).
You know that, in actuality, Dr Wannabee is not certified
by any legitimate board, didn’t even finish residency (a
nonsurgical one, at that), and operates in a noncertified
office facility. Through the years, you have seen many
poor results from Dr Wannabee, yet the practice seems to
prosper, at least as evidenced by a perpetual barrage of
advertising. Disappointed, you ask yourself why Ms Smith
made what, to you, is such a poor choice, why she is
seemingly happy with clearly inferior results, and—most
personally distressing—why she did not select you to do
her face-lift.
Dr Fiala’s excellent article, “What Do Patients Want?
Technical Quality Versus Functional Quality—A Literature
Review for Plastic Surgeons,” provides us with keen
insights into the potential origins of such a scenario.1 As
surgeons, we have striven for years to develop, refine, and
perfect our technical quality (TQ). However, as the author
clearly illustrates, patients are generally poorly equipped
to judge TQ. This is not particularly surprising, given that
even highly skilled and experienced aesthetic surgeons
may not always agree on TQ measures like aesthetic outcomes. In addition, such outcomes have been historically
difficult to objectively quantify, as reflected in the paucity
of broadly accepted, validated aesthetic metrics.2 Patients,
of course, do desire TQ—after all, it is hard to imagine a
patient willingly accepting a suboptimal result—but they
also seek to be treated with respect, consideration, and
empathy. Patients want to feel valued and to receive value
in turn. The author shows us compelling evidence that from
a patient perspective, such emotional, interactive, and value
factors (ie, functional quality, FQ), are as important—or
even more important—than the end result (TQ). In aesthetic surgery in particular, the impact of FQ is further
magnified because the patient’s innate judgment of FQ
serves as a substitute for more elusive TQ assessments.
In the same way that patients have difficulty assessing
clinical outcomes (TQ) directly, they also face challenges
in assessing indicators that may predict TQ. One such
indicator is board-certification. A positive correlation
between quality and board-certification is both intuitive
and logical: after all, board-certification requires years of
training in competitive, credentialed programs combined
with independent practice experience and rigorous testing.
While not a guarantee of TQ in individual circumstances,
board-certification is increasingly correlated with improved
outcomes3-5 and is seen as playing a critical role in public
accountability and the care quality movement.6,7 Patients
intuitively sense this correlation between certification and
quality, overwhelmingly feeling that physicians should be
required to be board-certified (98%).8 Patients also consider board-certification a critical factor when choosing a
physician. According to a 2008 American Board of Medical
Specialties public survey, 91% of respondents indicated
that board-certification is “very important” or “important”
in choosing a doctor, and 25% indicated that boardcertification is the most important factor in selecting a doctor.9 Patients also feel that physicians should be required
Dr Eaves is Associate Clinical Professor at The University of North
Carolina, Charlotte, North Carolina.
Corresponding Author:
Dr Felmont F. Eaves III, Charlotte Plastic Surgery, 11220 Elm Lane,
Suite 106, Charlotte, NC 28277, USA.
E-mail: [email protected]
Eaves763
to maintain their certification, with three-fourths indicating that they would be very likely to find another specialist
if their current doctor’s certification had expired.8,10 Given
a choice between a board-certified physician and a nonboard-certified physician who was recommended by family or friends, patients would overwhelmingly (75% versus
23%) choose the board-certified physician.11
A problem arises, however, because patients may not
be able to distinguish between legitimate boards and a
cornucopia of “junk” boards that fabricate an aura of credibility. To the patient, if they hear “board-certified” in any
permutation of or combination with “plastic,” “cosmetic,”
or “aesthetic,” then they may be mistakenly satisfied with
this predictor of TQ. Unfortunately, although patients do
care about board-certification and training, only one-third
actually inquire about their doctor’s certification and only
21% make the extra effort to verify the credentials online.8
In addition, patients may not identify the scope of practice
“drift,” where the physician’s actual practice does not align
with his or her training background or board-certification.
Sadly, deceit in the communication of credentials and
training is all too common, propagated by strategies ranging from grandiose but meaningless certificates to the
convenient omission of training and certification details.
Similarly, multiple specialty societies have emerged with
inflated names and implied credibility that do not align
with loose membership requirements. Whether rooted in
simple ineptitude, convenient confabulation, or sinister
deception, such practitioners and organizations mislead
the public.
Just as ignorance or misrepresentation emasculates the
certification indicator of TQ, the explosion of direct-toconsumer advertising (DTCA) by unqualified physicians,
medical device manufacturers, and branded procedure
companies further confuses credentials and creates a fictitious sense of TQ. Board-certified plastic surgeons and
other core groups have embraced significant ethical guidelines concerning appropriate marketing; however, many
other groups, including noncore providers working outside
their scope of training, are not so constrained. Hyperbolic
claims of international accolades, superior abilities, and
spectacular results subsequently abound, and publicized
doctor ratings that are not based on legitimate objective
measures, patient feedback, or peer ranking magnify this
distortion. DTCA of restricted medical devices is currently
only a fraction of the DTCA of drugs; however, such marketing is growing and raises significant concerns related to
the expertise of the public to assess ad claims, pressure on
physicians to utilize unnecessary or suboptimal devices,
and damage to the physician–patient relationship.12 From
a patient standpoint, DTCA of medical devices can be
demonstrated to have a significant impact on surgeon
selection and patient decision-making,13 which is, of
course, the intent of the advertising in the first place.
Inefficiencies in the marketplace and vast resources provide companies with a distinct advantage to unduly influence patient decision-making, creating for themselves a
conflicted, double economic role both as drivers of demand
and as suppliers of that demand.14 Companies that find
their devices shunned by legitimate, core providers may
shift their strategy toward noncore physicians, leveraging
their public marketing savvy to imply credibility to any
willing provider of their product. Similarly “branded techniques,” also driven with extensive DTCA, create impressions of technique and provider TQ even in the absence of
any hint of supporting medical literature. Companies that
market branded techniques have tremendous profit incentives to promote their procedures and providers at all
costs, including minimizing risks, inflating results, and
suppressing criticism by physicians and patients. Adding
insult to injury, if qualified, appropriate providers like
board-certified plastic surgeons succumb to the pressure to
embrace ineffective devices or branded techniques for
marketing advantage, the specialty is undermined, colleagues and patients are harmed, and the devices, technique, and associated noncore providers are validated in
the public’s eye. Patient testimonials may even be fabricated by companies themselves15,16 and should be considered with skepticism. With little accountability in an
Internet and social-media-driven world of hyperbolic marketing, it has become virtually impossible for patients to
accurately assess the plethora of marketing claims. Every
doctor is “world famous,” every device is “breakthrough,”
and patients can “painlessly reverse their aging by 20
years in an hour.” Legitimate, hard-earned credentials and
abilities drown in a sea of falsehood.
Such an environment within the realm of aesthetic surgery creates an enhanced potential for low-end disruption.
Low-end disruption occurs when new players insert themselves into an established market at a lower cost and quality point (“just good enough”), and once gaining an initial
foothold, these potential disruptors attempt to increase
quality and cost to increase profit margin.17,18 This certainly seems to describe the barrage of newcomers entering the aesthetic surgery marketplace—that is, noncore
providers, branded procedures, and unsubstantiated new
devices. Because the public is unable to fully assess TQ,
the quality and value of a product or service is uncoupled
from market feedback, and this market inefficiency both
perpetuates poor quality and further potentiates disruption. Forces within the aesthetic surgery marketplace have
capitalized on these market deficiencies. For instance,
obviously bogus devices and potions continue to flourish,
and the lovely office and friendly staff provided by the Dr
Wannabees—creating an impression of TQ and legitimacy—
ensnare some patients. As a consequence, the Ms Smiths
may receive ineffective, inappropriate, and even unsafe
care. Patient safety is not a cheap, interchangeable widget
that can be “just good enough.”
Recent developments suggest that this “wild west,”
“any claim goes” environment may be finally starting to
swing toward one that is healthier and more transparent,
both for medicine in general and for plastic surgery. For
example, educational campaigns about “white coat”
deception and truthful medical credential advertising are
now being actively waged by plastic surgery organizations19 as well as some other medical associations and
state legislatures. California, Florida, Louisiana, and Texas
764
have already passed laws and regulations delineating
specifically how “board-certification” must be disclosed in
advertising, and other states and the federal government
are considering similar legislation.20,21 The Federation of
State Medical Boards recognizes the need to protect the
public from the “unprofessional, improper, incompetent,
unlawful, fraudulent and/or deceptive practice of medicine.”22 One of the ways that state medical boards can
grapple with ongoing quality assurances and physician
drift is through the adoption of “maintenance of licensure
(MOL),” requiring both ongoing education and a demonstration of competency in the actual area of practice.23
Physicians who participate in continuous specialty certification (Maintenance of Certification, MOC) through an
American Board of Medical Specialties (ABMS) or
American Osteopathic Association Bureau of Osteopathic
Specialists (AOA BOS) program are already fulfilling the
intent of MOL,24 and the developers of MOL have wisely
included assurances of both TQ and FQ in the process.23
Regulatory policies that address scope of practice drift by
holding physicians working outside of their core competency accountable to the same standards as appropriately
trained specialists further supplement this assurance of
competency.25
Another potential avenue to improve the dysfunctional
marketplace is to hold groups and individuals accountable
for untrue marketing claims and to reestablish the link
between quality and rewards. Different governmental
agencies are ultimately responsible for enforcing rules
against false or unapproved claims. Depending on whether
a medical device is restricted by the Food and Drug
Administration (FDA), either FDA (for restricted devices)
or the Federal Trade Commission (FTC, for unrestricted
devices) will have this authority.26 For restricted medical
devices, Congress is beginning to consider how DTCA of
medical devices differs from DTCA of drugs and how to
close loopholes in the legislation that permit unapproved
marketing claims, for example by surrogate third parties.26
Perhaps somewhat encouraging is the recent settlement by
FTC related to unsubstantiated claims that creams reduced
patient body size, with further restrictions placed on “the
company from claiming that any drug, dietary supplement, or cosmetic causes weight or fat loss or a reduction
in body size, unless the claim is backed by two randomized, double-blind, placebo-controlled human clinical
studies.”27 Even this isolated, lonely insertion of evidencebased medicine (EBM) principles into marketing claims is
deeply gratifying.
Efforts to improve transparency, competency, and
accountability are not specific to plastic surgery, but are
quality-of-care and ethical issues that broadly affect society.
These are not anticompetitive attitudes or “turf war” strategies. Plastic surgeons recognize that there are many examples of overlap between specialties—including some areas
of aesthetic surgery and cosmetic medicine—in which
doctors are appropriately working within their scope of
training and board-certification, expanding patient choices.
However, by standardizing physicians’ methods of reporting training and certification, patients will be better
Aesthetic Surgery Journal 32(6)
informed to make decisions pertaining to what training
and qualifications they feel are appropriate in their own
physician, and when training and qualifications do not
align with their needs. Basic competency should be
assured by demonstration of skills and knowledge within
the practice area in which a physician works. In addition,
more balanced, transparent, and complete information
being provided to the public will lead to better provider
and treatment choices of medical devices and all procedures, including branded procedures. When misleading
marketing of providers, products, devices, or procedures
occurs, the public is harmed, but when marketing is truthful, the public becomes more informed. We must therefore
strive to educate the public and help illuminate deceptive
tactics that can lead to patient harm. We need to be
emboldened to openly speak the truth; when confronted
with deceptive marketing, incompetent practitioners, or
unsafe medical devices, it is our duty to the public to make
these known. President Harry S. Truman understood the
need to illuminate and confront deceptive tactics: “That’s
plain hokum. It’s an old political trick: ‘If you can’t convince ’em, confuse ’em.’ But this time it won’t work.”28
It is also our obligation to continue efforts to advance
quality in our training, our education, and our practices,
both as individuals and together as members of a specialty. Improvement is a matter not just of increasing our
knowledge, but also of adopting a continuous quality
improvement culture that embraces evidence-based
decision-making, improves systems and processes, and
nurtures the right culture and communication skills.29 This
triad of components is similar to the Toyota Production
System (TPS) and lean manufacturing principles that have
been implemented worldwide to elevate quality in numerous industries, and these concepts are applicable to
improvement in FQ30-34 in the same way they are to
improvement in TQ.35-37 In fact, viewed from another perspective, FQ and TQ are both manifestations of the successful implementation of these 3 components, which is
one potential explanation for the partial correlation
between FQ and TQ that patients innately perceive. For
example, a practice that develops good systems and processes for implementing protocols for venous thromboembolism prophylaxis and preoperative medical clearance
(TQ markers) will have the skills to optimize systems and
processes for streamlining patient scheduling and timely
callbacks (FQ markers). Similarly, a practice culture that is
respectful, considerate, and professional not only enhances
communication between staff members to reduce medical
errors (TQ marker) but also promotes compassion and
empathy to patients (FQ markers). Finally, just as we can
use EBM principles to guide our clinical decision-making
and improve clinical results (TQ), we can also study similar cognitive processes to optimize our customer care (FQ)
and generate greater patient satisfaction. Validated and
functional metrics are critical in applying such principles.
Currently, body-image and quality-of-life measures—
reflecting both TQ and FQ—are our best tools for determining aesthetic surgery outcomes.2 As the specialty
continues to struggle to develop validated metrics of TQ,
Eaves765
an emphasis on such patient-derived satisfaction metrics
will be extremely helpful.38,39
As Dr Fiala has shown, improving our FQ can reap
great benefits, and for many reasons plastic surgery practices should put similar efforts into developing FQ as TQ.
Applying cognitive effort, system and process improvement, and culture development that fosters FQ will simultaneously promote TQ improvements and patient safety.
Increasing FQ also counteracts disruptive forces by increasing patient satisfaction and value sense, thus improving
competitiveness. Such efforts also meet our patients’
expectations for FQ; the same ABMS survey that showed
that 91% of the public puts great emphasis on boardcertification when selecting their physician also showed
that even higher percentages consider measures of FQ such
as bedside skills or communication (95%), having a professional and friendly staff (97%), and returning phone calls
(97%) when making a selection.9 Because FQ involves
every interaction that a patient has with a practice, any
strategy to improve FQ must promote culture and FQ skills
of our staff. Without their buy-in, efforts at systematic and
meaningful FQ improvement are doomed. Finally, improving FQ will be worth the efforts for the simple joy of a
happy practice—for ourselves, our staffs, and our patients.
Disclosures
The author declared no potential conflicts of interest with
respect to the research, authorship, and publication of this
article.
Funding
The author received no financial support for the research,
authorship, and publication of this article.
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