Surgical advertising restricted but still possible in some countries

Many surgeons would like marketing restrictions eased but are afraid some colleagues would go “too far.”

Refractive surgeons in many countries are exploring ways of marketing their services, despite written and unwritten prohibitions on medical advertising. Information sessions, an informative Web site and a surgeon’s solid reputation are some ways to draw patients into refractive clinics in countries with restrictions on the marketing of surgical procedures, according to sources.

Joerg Hassel, the senior nonmedical partner in Prof. Dr. med. Thomas F. Neuhann’s eye clinic in Munich, said it is difficult to market any surgery in Germany because of the restrictions on advertising.

According to Michael C. Knorz, MD, of Mannheim, marketing restrictions in Germany allow surgeons to place only their name and phone number, and newspaper advertisement is illegal.

“The only thing doctors may do is place an ad that mentions a special informational event, like an evening session in the doctors clinic where he will present a talk on refractive surgery to patients. Any placative form of marketing — ‘I am the best...’ or ‘You will see 20/20...’ — is strictly illegal,” Dr. Knorz said.

“What we do in Germany is public relations work,” Mr. Hassel said. “We have informational evenings and our Internet homepage and things like that.

“In Germany, you need to be one of the big shots to step into the market because patients in Germany do not go to a ‘company,’ they go to a doctor. If you are a well-known, established doctor, then they land with you.

“The well-known doctors do a lot of refractive surgery. They are also doing cataract surgery, and the real high-volume surgeons do ‘eye surgery.’ They don’t just focus on refractive surgery. Word of mouth is the best way to get your name out there and become a well-known doctor,” he said.

Dr. Knorz added, “The Internet is another way to attract patients. We have a successful homepage that represents 16 refractive centers joined under one brand name. The homepage has proved very effective in increasing the volume of patients.”

He said surgeons should group with their colleagues to create a visible brand name to increase their center’s visibility.

“It makes little sense for every refractive surgeon to work on his own and compete with others, as market penetration is still very low. Also, they should focus on the Internet for their marketing because most patients in our target population use the Internet,” he said.

“In Germany, patients look for competence. Large centers grow far above average, compared to single-surgeon clinics, as patients feel specialized centers offer better quality. The best strategy for our practice was to join forces with 16 other large centers in Germany and Switzerland to form one brand name. Our Internet representation has proved to be the best marketing tool.”

Good and bad

Dr. Knorz said restrictions do have good and bad sides.

“I feel that marketing should be limited to high-quality information. Doctors should be able to tell what they are doing and explain the risks and benefits to their prospective patients. They should, on the other hand, not be allowed to place claims of superiority.”

He said there has been a gradual change in the marketing restrictions in Germany.

“Despite the fact that marketing is still illegal, doctors have their homepages on the Internet and inform about treatment options,” he said.

He said this practice is generally tolerated, and he expects it to be legal soon.

“However, it is very unlikely that marketing similar to that seen in the United States will ever be legal in Germany,” he added.

Disagreement in Spain

According to José L. Güell, MD, of Barcelona, Spain has no medical and surgical advertising as a professional rule, not because there are any real legal restrictions.

“Each day there are more colleagues and institutions using some nice and not-so-nice advertising procedures. This practice will definitely increase in the future, especially in medical specialties prone to using it, like plastic surgery, psychiatry or refractive surgery,” he said.

Dr. Güell said his practice is about half refractive surgery and half corneal surgery and diseases, and he basically gets new patients by word of mouth. However, he said he also receives patients through professional relationships with insurance companies and through other colleagues who are confident in his work but do not receive monetary incentives.

He said he does not think refractive advertising is a “bad” practice by itself, but its use can lead to “comic” situations if advertising is absolutely free, “like a smiling doctor offering a surgical procedure and one free day in Disney World.”

Dr. Güell said the advertising restrictions are for the protection of both patients and surgeons. “Obviously, both stop some freedom but the net result is better with them than without them. Personally, if you simply advertise what you really do, it is okay. If you include some more marketing, it is not the way to proceed for something related to medicine,” he said.

He noted that it is most important to promote real and truthful information to patients in advertising. He said it is also important to defend refractive surgery as an important subspecialty and not a study group of procedures that can be done anywhere and by anyone.

Eduardo Murube, MD, of Madrid, described the situation in Spain as “wandering between a classic deontology in which the prestige of doctors or clinics must be spread by word of mouth of the patients, whose opinion varies according to their clinical results, and a modern marketing system in which prestige is acquired through the mass media based on more or less gratuitous remarks.”

Dr. Murube said legislation and ethics and the medical code are so “confused and vague that almost everything is possible.”

“Nevertheless, most ophthalmologists are extremely discreet. But some surpass these limits, especially those related to nonmedical financial enterprises,” he said.

Dr. Murube said he believes health should be encouraged by any method. However, he said, advertising of refractive surgery does not promote health, only the business of a doctor or entity. “Thus, it is biased by nonmedical interests.”

“Personally, I think health advertising should be very restricted in the mass media,” he said. “Trade and commerce are another field. Advertising refractive surgery is not the same as advertising soap or toothpaste.”

Dr. Murube said European legislation on medical advertising should be developed.

“If not, the most aggressive clinics will affect the most discreet ones, which will either disappear or follow the others’ aggressive advertising policy in order to survive.”

Slow to spread

Hiroko Bissen-Miyajima, MD, of Tokyo, said there are strict limitations on marketing of refractive surgical procedures in Japan.

“We cannot advertise surgical procedures such as LASIK outside of the practice,” she said. “We are allowed to place the name of the clinic and doctors; however, we cannot advertise the doctor’s degree and specialization.”

To get around these restrictions, Dr. Bissen-Miyajima said some surgeons are instead advertising their books in shops and in taxis.

“We are only allowed to inform or advertise inside our clinic,” she said.

Dr. Bissen-Miyajima said she feels the advertising restrictions limit the quick spread of refractive surgery because people have no way to learn of the existence of such surgery unless they have come into the practice or have friends who have undergone refractive surgery.

“The advertisements in taxis may give them negative impressions. I think people believe [more readily] when they see or hear the advertisement in newspapers, journals, TV and radio, but this is not currently allowed,” she said.

Dr. Bissen-Miyajima said 30% of her practice is refractive surgery, and she too gets referrals from patients who have received LASIK or who know about the technique.

“I tell patients who have LASIK that we appreciate it if they tell their friends about it. Also, we can inform them of the surgical procedures in our practice. I put up some posters about the procedure and patients can get brochures about LASIK. Some of our patients take them home and inform their family,” she said.

Dr. Bissen-Miyajima said there really is not a push for change in Japan, although there are surgeons who wish they could advertise.

“On the other hand, we are afraid some aggressive surgeons will go too far if the restrictions change.”

Dr. Bissen-Miyajima said about 40,000 LASIK procedures were performed in Japan last year, and surgeons are not expecting a dramatic increase.

“Many surgeons say the main reason is the economic situation; however, I feel the basic problem is different,” she said. “Most people still doubt this type of surgery is safe to correct the refraction. If an organization, such as [Japanese Society of Cataract and Refractive Surgeons] or the Japanese Society of Ophthalmology officially advertised the procedure, or if the information about LASIK procedures could be seen in regular newspapers, the impression of the people will change.”

“To double the number of procedures, we need to inform or educate people in general,” Dr. Bissen-Miyajima said.

For Your Information:

• José L. Güell, MD, can be reached at Instituto de Microcirugia Ocular, Munner 10 Barcelona 08022, Spain; +(34) 93-253-1500; fax: +(34) 93-417-1301; e-mail: guell@imo.es.
• Joerg M. Hassel is co-owner of a refractive clinic with Prof. Dr. med. Thomas F. Neuhann. He can be reached at Geschäftsführer, CEO ALZ, Verbandssekretaer VSDAR e.V., ALZ Augenklinik Muenchen, Ridlerstrasse 75, D-80339 Munich, Germany +(49) 89-500-4-500; fax: +(49) 89-502-9-849; e-mail: hassel.alz@t-online.de; Web site: www.gutsehen.de.
• Michael Knorz, MD, can be reached at 14 Leibniz St., 68165 Mannheim, Germany; +(49) 621-383-3410; fax: +(49) 621-383-1984; e-mail: knorz@eyes.de.
• Eduardo Murube, MD, can be reached at Clinica Murube, San Modesto 44, E-28034, Madrid, Spain; +(34) 917-350-760; fax: +(34) 917-340-956; e-mail: murubejuan@terra.es.
• Hiroko Bissen-Miyajima, MD, can be reached at the Suidobashi Hospital, 2-9-18 Misaki-cho, Chiyoda-ku, Tokyo 101-0061, Japan; +(81) 3-3262-3421; fax: +(81) 3-5275-1912; e-mail: hirokobm@aol.com.