Differences of Search Engine Digital Footprints Between Podiatrists and Foot and Ankle Orthopaedic Surgeons: A Need to Join the Digital Era

Abstract

Background:

Search engines generate lists of the most relevant websites using a keyword or phrase query and are integral in guiding consumer preferences. Digital information is important in the field of medicine, influencing what patients learn about their conditions and who they choose as providers. When two types of healthcare providers, such as podiatry and foot and ankle orthopaedic surgeons (FAOSs), share an overlapping consumer market, whichever group has a larger digital footprint receives increased digital engagement.

Methods:

The Google search engine was used to query nine common foot and ankle–associated terms using a “search term + zip code” format for 150 zip codes divided into urban, suburban, and rural population densities. The first 10 results of each search were classified into one of five categories. Site content was classified as podiatry-oriented, other MD/DO-oriented, or FAOS-oriented. Separately, a ratio between podiatrists and FAOSs was calculated for each population density group. Data were then normalized using this ratio and reanalyzed with the Wilcoxon signed-rank test with significance at P < 0.05.

Results:

Of 13,500 total search results, 4,992 (36.9%) were podiatry-oriented, 2,109 (15.6%) were other MD/DO-oriented, and 436 (3.2%) were FAOS-oriented. All geographic areas featured a higher number of podiatry than FAOS-oriented sites. FAOSs have more results per provider in urban areas (P < 0.001), although podiatrists had more in suburban and rural areas (P < 0.001, P < 0.001). Podiatrists have greater digital engagement in descriptive search terms. “Ankle replacement” has greater FAOS engagement in all three geographic areas.

Discussion:

Foot and ankle–related Internet search terms results are overwhelmingly composed of podiatry-oriented sites. Per provider, regional differences are demonstrated, with FAOS having more sites in urban areas only. FAOS scope-of-practice terms such as “ankle replacement” still retain greater engagement by FAOSs. Search engine optimization and saturation strategies should be considered.

Search result information of orthopaedic foot and ankle conditions has sparked interest since the late 1990s.¹ Through the rapid development of the Internet, search results have been continually tailored to the growing consumer market. The field of medicine has become more interactive and collaborative because patients and professionals now have vast amounts of readily available information accessible through Internet search engines.² Google is currently the most widely used search engine, comprising up to 80% of the market.³ Google search frequency is increasingly used by the general public to search for information about musculoskeletal conditions, and a higher search volume for a given procedure is correlated with how often the procedure is done.^4–6 These search results become increasingly important when two groups, such as foot and ankle orthopaedic surgeons (FAOSs) and podiatrists, share an overlapping consumer market.

Current literature often compares FAOSs and podiatrists. FAOSs routinely treat foot and ankle trauma but also conduct more complex procedures while podiatrists conduct more routine foot and ankle procedures, up to 54% market share of the five most common surgeries.^7,8 Orthopaedic surgeons are more concentrated in urban areas,⁹ and rural residents are shown to either travel farther or seek an alternative provider to receive orthopaedic care.^10,11 Given the small number of current and prospective FAOSs,^12,13 it is likely that podiatry has a larger online presence in suburban and rural areas given their greater overall numbers and wider distribution.⁹

Despite these differences, the digital engagement of FAOSs and podiatrists, particularly in different geographic areas, is still unclear. This study seeks to determine in which geographic regions FAOSs and podiatrists receive more digital engagement and which common foot and ankle–related search terms results are more heavily influenced by FAOS or podiatrists. We hypothesize that FAOSs have higher digital engagement in urban areas, whereas podiatrists receive higher digital engagement in suburban and rural areas. We also hypothesize that FAOSs and podiatrists differ in digital engagement for different search terms, influenced by their respective scopes of practice and interests.

Methods

US zip codes were obtained from SimpleMaps (Pareto Software LLC) and sorted into three geographic regions based on population density in accordance with the Medicare Modernization Act of 2003.^14,15 Zip codes from US territories, zip codes with a population of zero, and zip codes within the first and fourth quartiles of population within each of the three population density groups were excluded. The study authors also developed nine search terms chosen based on search frequency data from Google Trends and relevance. Google Trends provides data on the relative frequency that specific terms are searched in a specified time range on the Google search engine.⁴ These terms were “foot pain,” “heel pain,” “ankle pain,” “ankle sprain,” “ankle fracture,” “ankle replacement,” “bunion,” “hammertoe,” and “Achilles tendinitis.” “Foot pain,” “heel pain,” and “ankle pain” were considered descriptive terms while “Achilles tendinitis,” “ankle sprain,” “ankle fracture,” “ankle replacement,” “bunion,” and “hammertoe” were considered diagnostic/procedural-based terms.

Using the “find a provider” section from the American Podiatric Medical Association and the American Orthopaedic Foot and Ankle Society websites,^16,17 members within a 20-mile radius of each zip code were identified. Using the aggregate numbers for each population density group, a ratio between podiatric providers and FAOSs was calculated (PF ratio). The PF ratios for urban, suburban, and rural areas were 11.67, 8.03, and 10.46, respectively. This ratio indicates that there are approximately 10.46 podiatrists per FAOS in the rural zip codes included in our study and are concordant with available data which demonstrate 1,100 active US members in the American Orthopaedic Foot and Ankle Society and approximately 10,700 active US members in the American Podiatric Medical Association.^17,18 The data were then normalized using the PF ratio for the respective population density group to take into account the difference in the number of podiatric providers and FAOSs and reanalyzed (normalized comparison).

A pilot study was conducted using 30 randomly selected zip codes from each geographic area and a single search term. A power analysis using G*Power 3.1.9.7 was conducted using the mean number of FAOS-oriented and podiatry-oriented results.^19,20 After assessing the normalized comparison, 185 Google searches in urban areas, 424 searches in suburban areas, and 105 searches in rural areas would be needed to determine a notable difference for overall results with a power of 0.80. Based on the results from the pilot study, the final methodological plan was designed.

In total, 50 zip codes were randomly selected from each geographic region using the random generator from Microsoft Excel (Microsoft). Roosevelt, NY (zip code 11,575; pop. density: 3,725.5 people/square mile), Daytona Beach, FL (zip code 17,520, pop. density: 1,596.3 people/square mile), and Ramah, CO (zip code 80,832, pop. density: 1.2 people/square mile) are examples from the urban, suburban, and rural regions, respectively, with data provided from SimpleMaps.¹⁴ Using the above-described nine search terms, this generated 450 total Google searches per geographic area. The search terms were queried in the “search term 1 zip code format” (eg, “heel pain 12,345”), and the results were categorized into the following major categories: review sites, facepages, social media, news articles, and other (Figure 1). Review sites, facepages, social media, and news articles were further subdivided based on whether they were FAOS, non-FAOS MD/DO, or podiatric-oriented. This was first accomplished by determining whether the direct link to the site exclusively featured a FAOS, non-FAOS MD/DO, or podiatrist. If the link did not feature a specific provider, then the main page of the website was analyzed to determine the primary purpose or provider type of practice. For example, a private practice named “X Podiatric Associates” would be categorized as podiatry-oriented. If the direct link did not have a main page and the provider type was unclear, it was noted as “unclear provider” and was excluded from provider type data analyses. The top 10 ranked results of each search were analyzed, and the position of each result was logged. For analysis, position ranking was divided into three groups with “top” being positions 1 to 3 on the result page, “middle” being positions 4 to 7, and “bottom” being positions 8 to 10. Two reviewers conducted each Google search and resolved disagreements through discussion. Search result influence was minimized using an institutional proxy, using the Google Chrome Incognito mode, clearing browser data, and ensuring that no other windows were open. In addition, reviewers analyzed the same specific search result information simultaneously to minimize the effect that any other unknown factors could have on the result. This led to a total of 1,350 Google searches and the categorization of 13,500 search results from July to August 2021. Main study data were collected using REDCap electronic data capture tools.^21,22 Figure 1 presents the final website categories and examples. This study was Institutional Review Board exempt because all information was publicly available.

Figure 1.

Diagram showing descriptions and examples of website types.

Statistical analysis was conducted using Statistical Package for Social Sciences (SPSS; Version 28.0).²³ First, we analyzed the number of podiatric-oriented, other MD/DO-oriented, and FAOS-oriented sites for each category in each geographic region. Second, we examined the distribution of podiatric-oriented, other MD/DO-oriented, FAOS-oriented sites by individual search terms. Finally, we evaluated the search result rank position for podiatric-oriented, other MD/DO-oriented, and FAOS-oriented sites. The Shapiro-Wilks test of normality was used for all comparison groups to determine whether the data followed a normal distribution. Because the distribution of the number of Google results in all categories and all geographic regions were nonparametric (P < 0.001), the distributions of all three provider types were compared using Friedman tests, and if significant, followed by post hoc Wilcoxon signed-rank tests. After adjusting the data using the PF ratio for each geographic region, the distributions between the podiatric-oriented sites and the normalized FAOS-oriented sites were also compared using Wilcoxon signed-rank tests. These nonparametric statistical tests allow for the comparison of multiple groups and paired groups, respectively. Significance was set at P < 0.05, and a Bonferroni correction of P < 0.0125 to account for multiple comparisons was used for the Wilcoxon signed-rank tests. All statistical tests were two-tailed.

Results

For this study, 1,350 total Google searches were conducted and 13,500 total Google results were collected, of which 4,992 (36.9%) were podiatry-oriented and 436 (3.2%) were FAOS-oriented (Figure 2). In addition, 2,109 (15.6%) were other MD/DO-oriented and 5,963 (44.2%) were not categorized as MD/DO or podiatry-oriented and excluded from this analysis. Among the most prevalent results in this last group were insurance-related websites and advertising websites, which made up 1,073 (7.9%) and 781 (5.8%) of the total searches, respectively.

Figure 2.

Graph showing the distribution of Google search results by provider type and excluded results.

We first analyzed the total number of podiatry, FAOS, and other MD/DO-oriented sites by category for all three geographic regions (Figure 3, Supplemental Table 1, http://links.lww.com/JAAOS/A803). All categories in all population areas with the exception of “news” differed markedly in the number of baseline web results by the provider. In these categories, podiatric-oriented websites were more prevalent than FAOS or other MD/DO-oriented websites. In the normalized comparison, FAOSs had more web results per provider in urban areas overall (P = 0.011), although podiatrists had more in suburban (P < 0.001) and rural (P < 0.001) areas overall.

Figure 3.

Graph showing overall search result information by provider type, stratified by geographic area.

The distributions of website results of descriptive search terms (ankle pain, foot pain, and heel pain) were analyzed (Supplemental Table 2, http://links.lww.com/JAAOS/A804). In the baseline web results, podiatry-oriented websites were more numerous than FAOS-oriented or other MD/DO-oriented websites for all three terms in all three geographic areas, with the exception of “ankle pain” in rural areas, in which no differences between podiatry and other MD/DO-oriented results were found. After normalization, all descriptive search terms had greater podiatric-oriented search results overall in all geographic regions (P < 0.001 for all).

The distribution of results of diagnostic/procedural-based search terms (Achilles tendinitis, ankle replacement, ankle fracture, ankle sprain, bunion, and hammertoe) was also analyzed (Supplemental Table 3, http://links.lww.com/JAAOS/A805). In urban areas, all terms favored podiatry-oriented results over both FAOS-oriented and other MD/DO-oriented results in the baseline overall results, except for “ankle replacement” and “Achilles tendinitis.” After normalization, overall urban “ankle fracture” and “ankle replacement” results favored FAOS-oriented overall (P < 0.001, P < 0.001); “ankle sprain” results favored podiatrists after normalization (P = 0.003). The remainder of these terms did not differ markedly between FAOS and podiatric-oriented web results after normalization in urban areas.

In suburban areas, all terms except for “ankle replacement” and “Achilles tendinitis” favored podiatrists over both FAOSs and other MD/DOs in the baseline overall results. After normalization, “bunion” and “hammertoe” significantly favored podiatrists overall (P < 0.001, P < 0.001); “ankle replacement” favored FAOSs overall (P < 0.001). The other search terms were not markedly different after normalization in suburban areas.

In rural areas, only the search term “hammertoe” favored podiatry-oriented results over both FAOSs and other MD/DOs in the baseline overall results. Four terms favored podiatry over FAOSs in these baseline comparisons in rural areas. After normalization, “ankle sprain,” “bunion,” and “hammertoe” significantly favored podiatrists overall (P = 0.002, P < 0.001, P < 0.001), and “ankle replacement” significantly favored FAOSs after normalization (P < 0.001). The other search terms were not markedly different after normalization in rural areas.

“Ankle replacement” was the only search term in which other MD/DO-oriented results outnumbered both FAOS and podiatric-oriented results before normalization. In addition, “ankle replacement” was the only term that favored FAOSs overall in all three geographic areas after normalization (P < 0.001 for all).

Finally, the search result rank position was evaluated (Supplemental Table 4, http://links.lww.com/JAAOS/A806). Podiatrists have a higher number of overall web results than both FAOSs and other MD/DOs in all three search positions and in all geographic areas with the exception of the middle and bottom rank search positions in rural areas. After normalization, FAOSs in urban areas had significantly more sites overall in the top (P < 0.001) and bottom (P < 0.001) positions. However, podiatrists had significantly more overall sites in all positions in suburban and rural areas (P < 0.001 for all) and the middle position for urban areas (P < 0.001). In the urban region for all position ranks (top, middle, and bottom) after normalization, podiatrists had more “review” pages (P < 0.001, P < 0.001, P < 0.001) while FAOSs had more “facepages” (P < 0.001, P < 0.001, P < 0.001). No notable differences existed in “news” results between FAOSs and podiatrists for any geographic area or search result position.

Discussion

Podiatrists had a higher proportion of overall web results compared with FAOS with the exception of the “news” category. There are more than 10 times as many podiatrists in the United States, relative to FAOSs, and this is probably the main factor influencing this finding.^17,18 Although this result is not surprising, the reality is that most search engine results for foot and ankle relevant terms will more prominently display podiatry-oriented over FAOS-oriented content.

When the results were normalized to account for the increased number of podiatrists compared with that of FAOSs, this study was able to more accurately determine the digital engagement per provider. Overall, FAOSs receive more overall digital engagement in urban areas while podiatrists receive more digital engagement in suburban and rural areas. This finding is congruent with past studies which have demonstrated that urban areas may have up to twice as many orthopaedic surgeons per capita compared with rural areas.⁹ It is likely that this relative paucity of orthopaedic surgeons outside of cities contributes to the higher digital market share of podiatrists overall in these areas.^7,24 In addition, many academic centers and large medical groups are based in urban regions. Providers at these institutions have a wide array of resources at their disposal including marketing departments and web developers, potentially allowing for a disproportionately greater digital footprint than would otherwise be possible in a different environment.

The difference between FAOSs and podiatrists in “review” pages after normalization was somewhat surprising. After normalization, we anticipated a relatively similar number of FAOS and podiatrist “review” pages because each provider should only have one review page on a given review website. Theoretically, with equal digital footprints, FAOSs and podiatrists should not only have the same number of review pages per provider but also be featured equally in the top 10 search results. However, our results indicate that podiatrists have more review pages in the top 10 search results in the urban and suburban areas and FAOSs have more in the rural areas. Search engines including Google use proprietary algorithms to rank and present vast quantities of information. These formulas account for the relevance and usability of pages, the expertise of the source, the searcher’s location and search settings, and the freshness of the page content. Therefore, more heavily searched sites and pages with both greater and more recent content will rank higher on the search result page.²⁵ In addition, because providers accrue more ratings and comments on review sites, their position on Google search results also likely improves. Our findings demonstrate that different provider types do better digitally in different geographical regions.

Our study also aimed to further elucidate whether differences between search terms would tend to favor different provider types. We did this by developing terms and categorizing them as generally descriptive or diagnostic/procedural-based terms. For our three descriptive terms, the overall web result data favored podiatrists at baseline over FAOSs (Supplemental Table 2). Even after normalization, podiatrists have greater digital engagement for all three terms in all geographic areas, reflecting a more primary care role that many podiatrists serve for general foot and ankle conditions, particularly as patients try to find answers for their symptoms online. Notably, results were more varied in the diagnostic/procedural search terms (Supplemental Table 3). For example, the terms “ankle replacement” and “Achilles tendinitis” were not found to be markedly greater for podiatrists than the other provider types in any geographic area. Normalization allowed for an even clearer view of these results: Podiatrists received higher digital engagement for terms popular within their scope of practice, such as “bunion” and “hammertoe” in suburban and rural areas. However, with terms such as “ankle replacement,” of which a vast majority are done by FAOSs,²⁶ FAOSs receive more digital engagement per provider in all geographic regions after normalization. Therefore, it seems that scope-of-practice differences between podiatrists and FAOSs influence the digital engagement of various terms. Even so, this effect may not be as large as expected; for example, podiatrists still have a greater number of overall web results for “ankle replacement” in suburban areas.

Generally, our analysis of the search term type suggests that diagnostic/procedural search terms are less likely to lead to a notable difference between FAOS and podiatric-oriented web results, unless that particular search term falls heavily into one providers’ scope of practice. For instance, after normalization in urban areas, podiatric-oriented results were only favored in one of the six diagnostic/procedural terms. This is contrasted with the descriptive search terms in which podiatrists were favored in all three terms. However, as the categorization of every possible search term of interest into descriptive or diagnostic categories is impossible, our results are potentially biased by our selected search terms.

The search result position data suggest that the same trends of popular websites for one provider type overall will be reflected, regardless of the position of the search result. FAOSs receive greater digital engagement in “facepages” in urban areas, whether the result is at the top, middle, or bottom of the Google search result page. This is contrasted with “review” pages, which are dominated by podiatrists in urban areas no matter the position on the search result. This could be due to external factors: “Facepages” are often controlled directly by the practitioner or their medical group, who can choose to more fully advertise or display their websites. However, “review” pages cannot be controlled by any health system and simply depend on the popularity for that individual site.

The search result position continues to be important because an estimated 92% of traffic of a Google search goes to the first page.²⁷ Therefore, search engine optimization strategies at all levels will aid FAOSs in increasing their digital footprint. From the organizational level, technical changes such as ensuring Secure Socket Layer authentication and including keywords of interest in the URL of websites improve the Google search position.²⁸ At the individual and group levels, FAOSs must assist in curating their practice websites. Expanding educational and “facepage” information and adding features such as blog posts should improve visibility because more text has been shown to give more preferable Google search rankings.²⁸

Finally, we note that “review” pages and “facepages” were much more prevalent than “social media” and “news” pages in our overall results. In the urban area aggregate data, “review” and “facepages” together comprised 97% of the podiatrist-oriented results and 93% of the FAOS-oriented results. Although social media has become increasingly popular among healthcare providers and residency programs, our study demonstrates that “facepages” and “review” sites still dominate the available information of FAOSs and podiatrists in all geographic regions.^29,30 Social media has been seen as a new means of healthcare delivery,³¹ and built-in social media support on other website types has also been demonstrated to be a search engine maximization strategy.^28,32 Therefore, these findings suggest that providers and organizations have room for expansion in this area, especially in adapting to and incorporating new social media networks as they become popular. News articles were among the lowest results; this is not surprising because most people who use online resources to search foot and ankle conditions are likely to be looking to find a physician or podiatrist, rather than online news stories that may or may not be relevant to their condition.

This study has several strengths and provides a wealth of information regarding the current online presence of podiatrists and FAOSs. This study was designed to ensure randomization and reduce bias, and a wide array of popular and relevant Google search terms were included. By using a well-established search engine and collecting data from all geographic regions in the United States, we provide a relevant and detailed examination of the current state of FAOS and podiatric digital influence on foot and ankle–related search terms.

Our study also has several weaknesses. First, it is possible that search results vary from search to search depending on multiple factors that we controlled for in the study design, but that would not be regulated in the real world. Second, some sites were difficult to classify. Many sites include different subsections that could be included in alternative site categories if analyzed independently from the greater site. The overall site type was used in this situation, but this technique could lead to relative underrepresentation of some categories. One example of this would be with educational sites. A large share of educational material comes from medical providers and groups to attract patients to their facepage and practice. This is consistent with several previous studies in which academic centers primarily use their online resources to market to patients.^33,34 We tried to minimize miscategorization by relying on two reviewers reaching a consensus; moreover, during our pilot study, we tried to standardize the site classification process. Third, we were unable to incorporate a per provider non-FAOS MD/DO analysis because it was difficult to accurately ascertain the population of these physicians in each particular zip code. Finally, our study was unable to include sponsored advertisements because their presence on a result page was likely influenced by hidden factors outside of our control and were found to vary to some degree from search to search, despite using the same search terms. Competition in advertisements in the foot and ankle realm is also increasingly relevant as direct-to-consumer advertising throughout health care has vastly increased from 1997 to 2016.³⁵ Although not specifically analyzed in this study, advertisements made up a sizable 5.9% of the total 13,500 Google results. Therefore, a future study more specifically analyzing advertisements and their position in foot and ankle–specific terminology search results is warranted.

This observational study on Google search result information for common foot and ankle–related terms provides new information on the digital influence provided by FAOSs and podiatrists. Overall, podiatrist-oriented sites are markedly more common for all geographic population density regions and in almost all categories. The results of this study do support our hypothesis that FAOSs receive more digital engagement per provider in areas where they are heavily concentrated, represented by urban areas in our study. Particularly, provider facepages among FAOSs received more digital engagement than their podiatrist counterparts after normalizing for the ratio of podiatrist to FAOS for each region. However, podiatrists receive more overall digital engagement in suburban and rural areas even after adjusting for the relative number of providers. This means that on average, each individual podiatrist in those areas has a larger digital footprint than each foot and ankle orthopaedic surgeon. Specific search terms influenced digital engagement heavily, particularly if the treatment for certain conditions was dominated by one provider type.

Multiple approaches should be considered by foot and ankle providers to improve their digital engagement. Search engine optimization and saturation strategies by FAOSs should be considered at the individual, group practice, and specialty organization levels.²⁸ Furthermore, expansion into the social media realm should be considered to leverage additional markets currently underserved by the available online resources. As access to an expanding set of digital information continues to become woven through the fabric of society, failure to adapt to these changes risks becoming less competitive in the future.