Advertising by orthopaedic surgeons: the tension between professionalism and commercialism

Translating guidelines into practice is required to maintain the balance between practitioner autonomy and accountability

Medical professionals assure us that they will only provide care that limits harm (non‐maleficence) and promotes the best outcomes (beneficence) for patients. The basis of this social contract is the expectation of integrity, morality, and altruism in their business practices, making doctors trustworthy sources of good health care. A doctor’s first duty is to their patient, a dictum as relevant today as it was for Hippocrates. In our complex society, it is more important than ever that doctors are trusted by their patients. In return, doctors enjoy autonomy of practice, status in society, and self‐regulation.

In their cross‐sectional survey of 81 randomly selected Australian Orthopaedic Association (AOA) member surgeons and a sample of 59 surgeons identified by Google searches, Ryan and colleagues found that only one‐quarter of the AOA‐accredited surgeons and one‐tenth of the Google top‐listed surgeons were fully compliant with medical board and AOA guidelines for advertising.1 The authors highlight the gap between practice and policy and call for stricter enforcement of professional advertising guidelines. The strengths of their study were its prospective and de‐identified nature, covering surgeons with roughly representative sub‐specialty and geographic distributions. Weaknesses included the small numbers of surgeons surveyed, particularly when categorised by sub‐speciality, which should make interpretation cautious. Nonetheless, this study provides an important insight into the directions of advertising practice that may indicate a shift in professional norms.

The internet is an invaluable resource for patients seeking to better understand their conditions and to inform themselves about care options.2 It has shifted the balance in the doctor–patient relationship, leading to shared decision‐making, promotion of evidence‐based practices, and co‐design of care strategies. In an ecosystem increasingly burdened by cost and demand, the addition of industrial drivers, institutional imperatives, and direct‐to‐patient marketing has changed the health care landscape and raised the influence of commercialisation in health care.3 Correspondingly, patients are now often referred to as “clients” and treatments as “care packages”, presented with business cases for their adoption.

The internet has also enabled health care institutions and providers to promote their knowledge and expertise. A clear consequence is the potential for health providers to influence the direction of referrals through the information they publish online.4 What is unclear, however, is the quality of this information and the veracity of their medical claims. The adoption of systems of certification for online information quality (eg, the HONCode; https://www.hon.ch/en) has been limited. For example, a recent study found that only 9% of websites providing information on total joint replacement were accredited by HONCode, and most of these sites were operated by governmental or educational agencies.5

Advertising for medical services involves a tension that reflects a conscious awareness of the importance of professionalism. Medical societies have taken issue with how treatments have been advertised by individual practitioners, and have published guidelines to ensure that accepted standards are reflected by their professional frameworks. In Australia, the Australian Health Practitioner Regulation Agency (AHPRA) and fifteen national boards collaborate to “ensure the community has access to a safe health workforce across all professions registered under the National Registration and Accreditation Scheme”.6 AHPRA is explicit about its role in overseeing the implementation of section 133 of the Health Practitioner Regulation National Law, and has provided guidance on how it should be implemented.7

A recent bill introduced into the Queensland parliament, however, seeks to change the National Law by removing the ban on regulated health services using patient testimonials in advertising.8 This will no doubt be controversial, as the rights of patients to inform and be informed about each other’s experiences must be balanced against the potential for professionals to exploit this consideration for commercial purposes.

The question of why there is a gap between policy and practice therefore remains. While stricter enforcement may be one response,1 translating ideas into practice in a sustainable and meaningful way is difficult. Doctors face translational barriers when introducing therapies and must resort to careful implementation strategies;9 translating ethical concepts into enduring practice may require similar approaches. Learned societies and professional associations have important roles to play in leading the translation of guidelines into practical observances, and in highlighting the important balance between autonomy and accountability.