Patient Perspectives on Selecting an Academic Aesthetic Surgeon: A Qualitative Analysis

Abstract

Background:

Growth of the aesthetic surgery marketplace has increased patient choice in provider selection. This study aims to characterize how patients choose an aesthetic surgeon, identify knowledge gaps in this decision-making process, and understand why patients select academic aesthetic surgeons.

Methods:

A qualitative interview study of aesthetic surgery patients from an academic center was conducted. Purposive sampling maximized representation regarding surgeon, surgery type, and patient demographics. An interview guide was developed in collaboration with content and methodology experts, then refined through pilot testing. Emergent themes were identified using a codebook constructed by grounded theory.

Results:

Thematic saturation was achieved with 24 patients. When selecting a surgeon, participants valued bedside manner (24/24) and past patients’ satisfaction (18/24). Most (16/24) participants ascribed low importance to board certification. Reasons given for choosing an academic practice included the institution’s reputation (13/24) and the availability of medical records and other specialties if complications arise (8/24). Participants demonstrated knowledge gaps regarding medical training and licensure. No (0/24) participant was aware that any licensed physician can offer aesthetic surgery, and nearly all (23/24) participants expressed discomfort with this.

Conclusions:

Patients prioritize subjective elements when selecting an aesthetic surgeon, relying less on objective and meaningful qualifications like board certification and training background. Academic aesthetic practice are valued because of reputation and ability to function as a medical home. Given the lack of public understanding regarding physician training. initiatives promoting transparency are needed to ensure patients can make safe, informed decisions.

Introduction

Over the past two decades, the number of aesthetic procedures performed in the United States has grown by almost 150 percent,¹ with the industry generating over $9 billion in revenue last year.² Concurrently, an increasing majority of Americans approve of aesthetic surgery.² With this rapid expansion and widespread public acceptance of aesthetic surgery, practitioners of various training backgrounds now offer aesthetic servces.^3–6 Since aesthetic surgery is not considered medically necessary, payment is outside the scope of health insurance coverage. The self-funded nature of the aesthetic marketplace allows patients complete autonomy when choosing providers because they are not constrained by insurance policies. This presents a unique context for investigating patient decision-making regarding provider selection.

Patients believe that choosing the “right” aesthetic surgeon can minimize the risk of complications.⁷ Multiple surveys have demonstrated that patients prioritize board certification when evaluating aesthetic surgery providers.^8–11 However, common misconceptions surrounding aesthetic surgeon training and credentials may hinder informed decision-making in this context. These include a lack of awareness that any licensed physician can practice aesthetic surgery and confusion regarding how certifying boards differ.^{9, 12} This study aimed to elucidate patients’ priorities when choosing an aesthetic surgeon and to investigate knowledge gaps relevant to this decision-making. We purposefully chose a robust academic aesthetic practice as our setting to investigate patients’ motivations for selecting this practice type. Given that they chose an academic plastic surgeon, we hypothesized that these patients would most value credentials such as board certification and be familiar with the training backgrounds of aesthetic surgeons.

Methods

Study Design

We used a standard qualitative approach to analyze patient perspectives on selecting an academic aesthetic surgeon.¹³ A semi-structured interview guide was developed in collaboration with content and methodology experts, then refined through cognitive interviewing and pilot testing. The final interview guide comprised 13 open-ended questions assessing patient decision-making when selecting an aesthetic surgeon and their understanding of physician credentials (Table 1; document, Supplemental Digital Content 1, full interview guide). Semi-structured interviews ensured that all participants were asked the same standardized prompts while allowing for further elaboration and clarification as needed. Qualitative methodology was chosen for this study because of its advantages when evaluating nuanced thought processes. With open-ended questions, participants can respond freely without the limitations imposed by predefined answer choices. This can provide insights into a study population’s perspectives not captured by surveys or other quantitative methodology.

TABLE 1.

Example Interview Questions^*

What factors were most important to you when deciding on a surgeon?

What signaled to you that Dr. [last name] was the right one for the job?

How familiar are you with the qualifications a doctor needs by law to perform aesthetic surgery?

When you see that a doctor is “board certified”, what does this signal to you?

^*Following standard semi-structured interview methodology, the interview guide was modified throughout the course of the study to further explore themes that emerged in earlier interviews.¹⁴

The Vanderbilt Institutional Review Board granted this study exempt status. Methodology followed the Consolidated Criteria for Reporting Qualitative Studies.¹⁴

Participant Recruitment

Patients were eligible if they underwent aesthetic surgery at Vanderbilt University Medical Center and were at least 18 years of age. Eligible patients were invited to participate in an in-person interview following a post-operative visit. A purposive sampling approach maximized representation regarding surgeon, type of surgery, and demographic characteristics (Table 2).

TABLE 2.

Participant Characteristics

	No. of Participants (%)
Age in years, median (IQR)	49.5 (14.8)
Gender
Female	20 (83.3)
Male	4 (16.7)
Race/ethnicity
White	20 (83.3)
Asian	1 (4.2)
Black	1 (4.2)
Hispanic	1 (4.2)
Multiracial	1 (4.2)
Surgeon
Attending A	8 (33.3)
Attending B	5 (12.5)
Attending C	3 (12.5)
Attending D	1 (4.2)
Attending E	1 (4.2)
Chief Resident F	4 (16.7)
Chief Resident G	1 (4.2)
Chief Resident H	1 (4.2)
Surgery type *
Exclusively body	18 (75.0)
Facial component	6 (25.0)
Complications
No	15 (62.5)
Yes	9 (37.5)

^*“Body” surgery was defined as a surgical procedure located below the clavicle (e.g., breast augmentation, abdominoplasty). “Facial” surgery was defined as a surgical procedure located at or above the clavicle (e.g., blepharoplasty, rhytidectomy).

Data Collection

24 patients were interviewed to achieve thematic saturation, or the point at which no new themes emerged with additional interviews.¹⁵ No participant withdrew from the study after initiating their interview. Interviews were completed between November 2021 and February 2022 by a single interviewer (S.C.) independent of patient care. Interviews ranged from 13 to 40 minutes, with an average length of 25 minutes. All interviews were audio recorded, professionally transcribed, and uploaded into the qualitative coding software NVivo (QSR International Pty Ltd.) for analysis.

Data Analysis

Using grounded theory, this study employed a standardized iterative process of inductive reasoning to identify themes within participants’ responses to interview questions.^{13, 16} This approach allows for data analysis to be unrestricted by a priori assumptions.^{13, 16} A multidisciplinary team of experts in plastic surgery, bioethics, and qualitative research independently reviewed four representative transcripts to identify emergent and structural themes. These themes were further developed and organized into a comprehensive codebook. Next, two coders (S.C., B.P.) independently applied this preliminary codebook to 33% of transcripts by constant comparison. All coding discrepancies were reconciled, and the codebook was revised to reach ≥80% intercoder agreement (κ>0.8).¹⁷ The finalized codebook was then applied to all interviews by the original interviewer (S.C.). All members of the research team reviewed, refined, and agreed upon the results.

Results

Factors Critical to Aesthetic Surgeon Selection

When selecting an aesthetic surgeon, participants valued bedside manner (24/24), patient satisfaction (18/24), and institutional affiliation (18/24). Regarding bedside manner, participants reported several dimensions to be important. Some commented that they prioritized an approachable affect (“She was very personable and down to earth” -Participant 16, Table 3), while others wished to develop rapport with their surgeon (“I have to have a connection” -Participant 24, Table 3). Participants also looked for a surgeon that provided thorough pre-operative counseling (“He took his time. It’s like any questions you need” -Participant 11, Table 3) and individualized care (“I wanted somebody that… made a plan with the patient instead of for the patient” -Participant 9, Table 3).

TABLE 3.

Quotes Representing Participants’ Attitudes and Values when Selecting an Aesthetic Surgeon

Theme Sub-theme	Representative Quote
Surgeon selection factors Bedside manner	“She was very personable and down to earth. And in my line of work, I’ve dealt with many surgeons and they’re not always personable and down to earth. She was.” “I have to have a connection. I mean, with him, immediately I felt it.” “He was very thorough in the beginning so I didn’t have to ask all the questions that I had in my mind or my head before I came. He answered them properly, but prior to me having to ask.” “He took his time. It’s like any questions you need. A lot of times you’re shoved into a room, and they give you a five-minute thing, and then out they go and that’s it. But he took his time with me.” “I wanted somebody that actually took the time to talk to the patient… to listen to them. And made a plan with the patient instead of for the patient.”
Patient satisfaction	“The best that a consumer can do is hope that they know someone that maybe has had surgery performed on them by this person or someone who works with them [the surgeon] or knows some inside information. Otherwise, it’s all a facade.” “I looked online and looked at reviews. Which sounds like I’m reviewing a couch, but it is important to me. It helps me [to] see people’s feedback of the surgeon that I’m going to go with.”
Institutional affiliation	“It’s just got a great reputation. I didn’t want to go to some place I didn’t know anything about.” “I just felt comfortable with my history being available, they could look at it and see my medicines, see what things that have happened to me in the past and what other surgeries I’ve had, and see my whole medical picture.” “I felt more comfortable having my surgery at Vanderbilt, knowing that if something went wrong, there is I don’t know how many other experienced physicians and surgeons in the building or in the area that would be able to step in… These smaller private practices, they don’t have that. If it’s a life-or-death situation, they’re going to try to save your life. But there’s an ambulance on the way to get you to the nearest hospital.”
Resident cosmetic clinic Lower cost	“I had to go through the resident clinic because my health insurance denied coverage. I was looking at other means of getting the surgery done without the exorbitant cost.”
Attending oversight	“You also have some of the top attending physicians that are assisting in these surgeries or stepping in on the critical points of your surgeries or even your care.”
Medical education	“That’s a good teaching moment. I’m always about being able to teach someone else something.”
Board certification Low importance	“I wasn’t honestly looking just to find a board certified physician. I was looking for someone that does cosmetic surgery. If they were board certified, great, but it wasn’t my primary focus in choosing a provider.” “I’m trusting that [if] I’m going with a Vanderbilt institution… There’s going to be some standard of care that has to be met in order to be part of this club. So I just assumed. I trusted Vanderbilt to know what was right and who to hire.” “There’s a lot of different boards depending on what field that they’re studying. And so there are boards in fields outside of medicine that mean nothing. That it’s just a random group of people that establish[ed] themselves and gave certifications… I just know that other fields I hear about certification processes, and I’m always, that’s it? That’s all you have to do?”
High importance	“They needed to be board certified so that you knew that their peers had said they’re proficient in this particular thing, that they can do it. It just gives a safety valve for us people out here trying to get this stuff done.”
Aesthetic surgeon qualifications Assumed additional credentials needed	“I mean, I’m pretty familiar. I know that they have to have certifications in plastics and cosmetics. They have to have their fellowships after med school.”
Uncomfortable	“I’m not very happy with that concept because I’m sure there are many botched surgeries because of someone that said, ‘Oh, I can make a lot of money doing this’.” “That would be like saying anybody that has [a] medical license could do a knee replacement. Just because they have a medical license doesn’t mean they know how to replace knees.” “I think it’s scary. I would’ve thought they had to have more than that. They don’t have years of experience… So that just seems like they don’t have enough education.”

Indicators of patient satisfaction—both direct referrals from a personal acquaintance and indirect referrals from patient reviews—were another factor influential in participants’ decision-making. Participants prioritized previous patients’ perceptions of a surgeon’s competency because they considered past patients to be the most trustworthy sources of information, with one commenting “Otherwise, it’s all a facade” (Participant 22, Table 3).

Notably, many participants stated that they valued an academic setting not only due to the institution’s reputation (13/24) but also because of an academic hospital’s ability to “see [a patient’s] whole medical picture” (Participant 2, Table 3), with health records and other specialties easily accessible if complications arise (8/24).

Among resident cosmetic clinic (RCC) patients (n=6), the substantially lower costs alongside attending oversight (4/6) contributed to participants choosing a chief resident as their primary surgeon, with one participant stating, “I was looking at other means of getting the surgery done without the exorbitant cost” (Participant 22, Table 3). Some (2/6) also valued the opportunity to participate in medical education and be part of a “teaching moment” (Participant 12, Table 3).

Views on Board Certification

Participants varied in how they perceived board certification. Some (8/24) ascribed it high importance, declaring that their surgeon “needed to be board certified” (Participant 11, Table 3). However, most (16/24) participants did not consider it in their decision. Exemplifying this theme, one participant remarked, “I was looking for someone that does cosmetic surgery. If they were board certified, great, but it wasn’t my primary focus in choosing a provider” (Participant 9, Table 3).

Several participants “just assumed” (Participant 15, Table 3) that their surgeon was board certified based on institutional affiliation. Furthermore, some participants devalued board certification due to comparisons with other fields’ less rigorous processes for earning this qualification. One participant remarked, “I just know that other fields I hear about certification processes, and I’m always, that’s it? That’s all you have to do?” (Participant 4, Table 3). When asked what board certification signaled to them, participants discussing a range of concepts (e.g., baseline competency, specialization, peer approval), but no consensus emerged (table, Supplemental Digital Content 2, representative quotes of participants’ conception of board certification).

Understanding of Aesthetic Surgeon Qualifications

All participants were either misinformed (16/24) or had no prior knowledge (8/24) when asked if they were familiar with the qualifications needed to offer aesthetic surgery. Of those participants who were misinformed, all believed that a physician needed training beyond the requirements of a medical license to perform aesthetic surgery. For example, one participant assumed “certifications in plastics and cosmetics” and “fellowships after med school” were required (Participant 16, Table 3).

After being taught about medical licensure during the interview (figure, Supplemental Digital Content 3, schematic of medical licensure process; resident physicians only need to complete internship before applying for a medical license in the state this study took place), almost all (23/24) participants expressed discomfort with how any licensed physician can legally perform aesthetic surgery. One participant remarked, “I’m sure there are many botched surgeries because of someone that said, ‘Oh, I can make a lot of money doing this’” (Participant 24, Table 3). When asked why they were uncomfortable, participants cited an absence of specialization within the medical licensure process, with one commenting “That would be like saying anybody that has [a] medical license could do a knee replacement” (Participant 23, Table 3). Participants were also concerned with the minimal level of training, stating that it “just seems like they don’t have enough education” with a medical license alone (Participant 11, Table 3).

Discussion

The last two decades have seen substantial growth of the aesthetic marketplace in the number of procedures performed, the revenue generated by these procedures, and the variety of practitioners performing these procedures.^1–6 This expanding market, along with the self-pay nature of aesthetic surgery, gives patients almost unlimited choice when selecting a provider. The purpose of this study was to assess how patients evaluate various factors when selecting an aesthetic surgeon and identify knowledge gaps in patients’ understanding of physician training and credentials. Furthermore, with the academic setting of this study, we aimed to investigate what attracts patients to an academic aesthetic center to unearth insights on how academic plastic surgeons can grow their aesthetic practices.

When asked what was most important when assessing aesthetic surgery providers, we found that participants prioritized subjective elements such as bedside manner and indicators of patient satisfaction. They valued the latter—whether direct referrals from personal acquaintances or indirect referrals from aggregated patient reviews—because they believed that past patients would describe their experiences honestly. Alongside traditional referrals by word of mouth, the rise of social media use by both providers and patients within the aesthetic surgery marketplace gives surgeons the means to reach a larger audience.^{12, 18–20} Displaying patient reviews prominently on professional websites and social media platforms can communicate high patient satisfaction and effectively attract patients to a practice. The emphasis participants placed on bedside manner also suggests there is value in aesthetic surgeons investing time during consultations to counsel patients, customize care, and build rapport.

Contrary to our hypothesis, objective indicators of competence, such as board certification, were considered less important by participants. These findings contrast with past surveys demonstrating that patients most value board certification when selecting an aesthetic surgeon.^8–11 The discrepancy may result from patients acknowledging a general association between board certification and competency but not personally prioritizing this qualification. This may lead patients to select board certification as a critical factor to provider selection in a multiple-choice format. In contrast, qualitative methodology utilizes open-ended questions, which elicits responses more representative of patients’ actual decision-making processes. Perhaps this is why interpersonal elements emerged as a prominent theme within this study’s qualitative interviews instead of credentials.

Because of its academic setting, this study provides guidance on growth strategies for academic aesthetic practices. Academic plastic surgery centers have traditionally focused their patient care on reconstructive surgery. However, it is critical for academic institutions to develop their aesthetic surgery practices not only for a robust revenue stream but also for trainee education as well as faculty recruitment and retention.^21–23 In this study, participants gave several reasons for choosing an academic setting. Not only did they value the institution’s reputation within the community, but they also viewed an academic practice as advantageous due to its ability to function as a medical home, with ease of access to health records and other specialists in case of complications. By emphasizing in marketing materials both their reputation and ability to serve as medical homes, academic centers can attract aesthetic patients by highlighting resources not as readily available in private practice settings. This may be especially effective for patients who already have an established history with an academic institution for other healthcare needs such as primary care.

Additionally, plastic surgery residency programs are often located at academic centers. Within training programs, RCCs have emerged as educational opportunities for senior plastic surgery residents to develop progressive independence while increasing aesthetic surgery exposure.^{23, 24} Study participants recognized the benefits of RCCs, namely the reduced cost with attending oversight and the opportunity to contribute to resident education. Along with the public perceiving RCCs as safe and being comfortable with receiving care from senior residents,²⁵ these findings support expanding RCCs to provide trainees with more graduated independence and exposure to aesthetic surgery. To effectively recruit patients, promotional materials should communicate how RCCs enhance resident education by offering aesthetic procedures at a discounted price while maintaining attending guidance during critical points of care. The success of RCCs also provides another argument for growing aesthetic surgery practices in academic settings.

Participants demonstrated knowledge gaps regarding physician training, medical licensure, and board certification. No participant demonstrated prior knowledge that any licensed physician can legally practice aesthetic surgery. Instead, they believed that physicians need specialized training before offering aesthetic surgery. Although a medical license is unrestricted from a legal standpoint, physicians consider other factors when developing their practice such as liability concerns, institutional policies, and personal ethics. Likewise, patients consider various factors when choosing an aesthetic surgeon.^{7–11, 26} Therefore, possessing sufficient understanding of their provider’s training background empowers patients to make informed decisions regarding provider selection. Furthermore, once participants in our study were educated on the credentialling requirements for aesthetic surgery providers, almost all expressed discomfort with how only a medical license is needed. This finding is concerning because it indicates that this knowledge gap may cause a patient to choose a different provider out of ignorance than they otherwise would have. In the aesthetic surgery marketplace, this is especially relevant because some aesthetic surgery providers practice outside the scope of their accredited residency training.^3–6 If patients assume that specialized training is required to legally perform aesthetic surgery, they may be unaware of these variations in training background and make less informed decisions as a result

While past survey studies have found that patients prioritize board certification when assessing aesthetic surgery providers,^8–11 this study did not replicate this finding, as most participants did not view board certification as important. Moreover, some assumed that their surgeon was board certified based on institutional affiliation. Although physicians at this study’s institution are required to be board certified or earn certification within their first four years of employment, this is not necessarily the case at all institutions. Therefore, in some instances, patient may mistakenly assume that their provider possesses additional credentials because of institutional affiliation alone. Additionally, other participants minimized bord certification by drawing comparisons to fields outside of medicine with less rigorous standards for earning this credential (e.g., personal training). These results collectively demonstrate the need for more robust patient education on board certification despite efforts like the American Society of Plastic Surgeons (ASPS)’s Trust ASPS public education campaign, which encourages patients to choose board-certified plastic surgeons and research the credentials of any aesthetic surgery provider.²⁷ Since participants demonstrated a nebulous understanding of what board certification signifies, public education should include content about how the stringent requirements for certification by the American Board of Plastic Surgery indicate both adequate specialized training and peer verification of competency and safety.

This study has limitations. Participant recruitment took place at a single academic center, which is why a purposeful sampling approach to maximize diversity was used. Although most aesthetic surgery occurs in private practice,¹ we chose to interview patients from an academic setting to understand their motivations for choosing this practice type. This is because we also wanted to investigate how academic plastic surgery centers can expand their aesthetic practices. Qualitative studies aim to explore a range of patient perspectives on complex subjects, so analysis is driven by thematic saturation, not statistical power. This limits quantitative conclusions from being drawn. Even with these limitations, this study captured nuanced patient perspectives not previously identified through surveys and other quantitative methods. These results can provide a framework to understand provider selection within the aesthetic marketplace more accurately and inform the direction of future studies.

Conclusions

Patients prioritize subjective elements such as bedside manner and measures of past patients’ satisfaction when selecting an aesthetic surgeon, while standardized indicators of competence such as board certification are less valued. Academic centers can attract aesthetic patients by focusing marketing efforts on their ability to act as medical homes in addition to their institutional reputations. Despite efforts by professional plastic surgery societies, there remains a lack of public understanding regarding physician training and aesthetic surgeon qualifications. Given the high degree of consumer discretion in the aesthetic surgery marketplace, public education campaigns, legislative initiatives, and individual provider-patient interactions should focus on increasing transparency to ensure patients can make safe, informed decisions.