- Email: [email protected]
Digital Footprint of Neurological Surgeons
Accepted Manuscript Digital Footprint of Neurological Surgeons Christopher Kim, B.S., Raghav Gupta, B.S., Aakash Shah, B.S., Evan Madill, B.A., Arpan V. Prabhu, B.S., Nitin Agarwal, M.D. PII:
S1878-8750(18)30253-5
DOI:
10.1016/j.wneu.2018.01.210
Reference:
WNEU 7408
To appear in:
World Neurosurgery
Received Date: 31 December 2017 Revised Date:
29 January 2018
Accepted Date: 30 January 2018
Please cite this article as: Kim C, Gupta R, Shah A, Madill E, Prabhu AV, Agarwal N, Digital Footprint of Neurological Surgeons, World Neurosurgery (2018), doi: 10.1016/j.wneu.2018.01.210. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Digital Footprint of Neurological Surgeons Christopher Kim, B.S.1*, Raghav Gupta, B.S.1*, Aakash Shah, B.S.1, Evan Madill, B.A.2, Arpan V. Prabhu, B.S.3, Nitin Agarwal, M.D.2 1
Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA 3 Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania USA These authors contributed equally
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Funding Statement This study was supported in part by a generous grant from The Beckwith Institute, awarded to Nitin Agarwal, M.D. Competing Interests Statement The authors have no personal, financial, or institutional interest with regards to the authorship and/or publication of this manuscript.
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Contributorship Statement NA, AVP, and RG were involved in the design and conception of this manuscript. NA, AVP, CK, and RG performed the literature search. EM created search tool and collected the data. CK and RG analyzed the data and compiled the tables and figures. CK, RG, and AS wrote the primary manuscript. NA and AVP critically reviewed the manuscript. All authors have approved the manuscript as it is written. Corresponding Author: Nitin Agarwal, M.D. Department of Neurosurgery University of Pittsburgh Medical Center Pittsburgh, Pennsylvania, USA Phone: 908-531-1947 Fax: 412-647-0989 Email: [email protected]
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Running Title: Neurosurgery Digital Footprint ABSTRACT
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Introduction Patients are increasingly turning to online resources to inquire about individual physicians and to gather health information. However, little research exists studying the online presence of neurosurgeons across the country. This study aims to characterize these online profiles and assess the scope of neurosurgeons' digital identities.
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Methods Medicare-participating neurological surgeons from the United States and Puerto Rico were identified using the Centers for Medicare and Medicaid Services (CMS) Physician Comparable Downloadable File. Each physician was characterized by his or her medical education, graduation year, city of practice, gender, and affiliation to an academic institution. Using a Google-based custom search tool, the top ten search results for each physician were extracted and categorized as one of the following: (1) physician, hospital, or healthcare system controlled, (2) third-party or government controlled, (3) social media based, (4) primary journal article, or (5) other.
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Results Amongst the physicians within the CMS database, 4,751 self-identified as being neurosurgeons, yielding a total of 45,875 URL search results pertinent to these physicians. Of the 4,751 neurosurgeons, 2,317 (48.8%) and 2,434 (51.2%) were classified as academic and nonacademic neurosurgeons, respectively. At least one search result was obtained for every physician. Hospital, healthcare system, or physician-controlled websites (18,206; 39.7%) and third-party websites (17,122; 37.3%) were the two most commonly observed domain types. Websites belonging to social media platforms accounted for 4,843 (10.6%) search results, and websites belonging to peer-reviewed academic journals accounted for 1,888 (4.1%) search results. The frequency with which a third-party domain appeared as the first search result was higher for nonacademic neurosurgeons as compared to academic neurosurgeons.
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Conclusions In general, neurosurgeons lacked a controllable online presence within their first page of Google search results. Third-party physician rating websites constituted about half of the search results, and a relative lack of social media websites was apparent. Still numerous opportunities exist for neurosurgeons to address this disparity. Keywords: Online Presence; Neurosurgery; Digital Footprint; Google; Physician Rating Sites; Online Health Care Information
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INTRODUCTION
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The growing accessibility of the Internet has revolutionized the patient-physician relationship and has resulted in online search engines being increasingly used to obtain information about individual healthcare providers.1-11 The accessibility and versatility of online search engines, such as Google, have enabled patients to capture a wealth of information instantaneously.12,13 However, an estimated 91% of patients do not look beyond the first 10 website hits that are obtained.14 In fact, website traffic drops 27% between the first and second website results, alone.14 Given these facts, consideration should be given with respect to the development and maintenance of physicians’ digital or “online” identities.
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In this study, we performed a demographic analysis of U.S. neurosurgeons’ digital profiles via an analysis and categorization of the top 10 Google search results for each provider. We paid attention to differences between academic and non-academic physicians and were careful in discriminating between physician-supported and physician-unsupported websites. As the Internet is a powerful medium by which patients identify and select physicians in an increasingly digital age, we believe the results of this study can serve as a guide for future neurosurgeons and physicians, alike. METHODS Institutional review board approval was not required for this study, as it utilized publicly available federal databases and online data sources. The methods utilized in this study were adapted from those first described by Vijayasarathi et al.15
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Study Population A list of neurosurgeons from the United States and Puerto Rico was obtained from the Centers for Medicare and Medicaid Services (CMS) Physician Comparable Downloadable File (PCNDF),16 which includes self-reported information regarding all physicians who are enrolled in Medicare’s fee-for-service plan, or roughly 90% of all U.S. physicians,15 The database was accessed and de-duplicated on Sept. 23, 2016. All unique entries were included for analysis (n=4,751 Data Collection The list of neurosurgeons was analyzed using Python v2.7 and Pandas, an open-source library dedicated to data manipulation and analysis in Python. Each physician was identified by NPI number, a unique identifier assigned by the PCNDF database. Data parameters mined from the PCNDF database included first name, last name, NPI number, gender, type of degree (MD/DO), medical school graduation year, and the city as well as state of practice. In the case where type of degree was not reported, an MD was assumed. Due to the large number of physicians to be queried, search results for individual physicians were obtained at scale by utilizing a Google Custom Search Engine (CSE), which was programmed in a manner previously reported by
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Prabhu et al17 and Vijayasarathi et al.15 Individual physicians were queried in the following manner: ‘[firstname] + [lastname] + [degree] + neurosurgeon + [city] + [state]’.
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For each neurosurgeon, up to 10 search result URLs were returned. These URLs were saved as a .csv file utilizing the Python Data Analysis Platform and Pandas.18 Neurosurgeons were assigned academic status if at least one of the URLs returned had an .edu address. 45,875 URLs were obtained for the 4,751 neurosurgeons queried. These URLs were arbitrarily divided into 3 groups, and 3 reviewers were assigned to manually classify the domain names of these URLs into one of five predetermined website categories presented in Supplementary Table 1. Each domain was reviewed by at least 2 reviewers; in the case where there was disagreement regarding the classification of a particular domain, a third reviewer was consulted to reach a consensus.
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Data Analysis The number and percentage of search results in each of the 5 website categories were determined; website category frequencies were determined for the academic, nonacademic, and total study population of neurosurgeons. Chi-square analysis was performed to determine if website category frequencies differed significantly between the two study sub-populations (academic and nonacademic). One-way Chi-square analysis was performed to determine if there existed a significant difference between the frequencies of the five website categories in the entire study population. Data analysis was performed with the Prism statistical analysis platform for Mac OS X version 7.0c (GraphPad Software, Inc., San Diego, CA). Significance was defined as p < 0.05.
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RESULTS According to the PCNDF database, 4,751 of the 1,038,373 (0.46%) physicians who participate in Medicare’s fee-for-service plan self-identified as neurosurgeons. Of these physicians, 2,317 (48.8%) and 2,434 (51.2%) identified as academic and nonacademic neurosurgeons, respectively. Additionally, all of the neurosurgeons identified in this study returned at least one Google search result. Demographics of the study population are shown in Table 1.
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Each of the 45,875 domains obtained were categorized into one of five website categories. The top 10 most frequently displayed domains are listed in Supplementary Table 2; the most common website domain was healthgrades.com, with 6,279 search results. Nine of the top 10 most frequently displayed domains were either third-party (5) or social media-controlled (4) websites. There was one primary academic journal website listed among the top 10 domains. Hospital, healthcare system, or physician-controlled websites (18,206; 39.7%) and third-party websites (17,122; 37.3%) were the two most commonly seen website categories within the top 10 search results for each neurosurgeon (Figure 1). Social media websites composed 4,843
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(10.6%) of all search results, and websites classified as 'other' or primary academic journals consisted of 3,816 (8.3%) and 1,888 (4.1%) of all search results, respectively. One-way Chisquare analysis across the entire study population demonstrated that the distribution of website domains across the five website categories was significantly different (p<0.0001). In addition, there was a statistically significant difference between top search results of academic and nonacademic neurosurgeons with regards to the website categories (p<0.0001). Of note, hospital, healthcare system, or physician-controlled websites consisted of 45.2% of the top search results for academic neurosurgeons, compared to 34.2% for their nonacademic counterparts' top search results.
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When an analysis was performed to assess the frequency with which individual website categories were found at each search position within the top 10 Google search results for U.S. and Puerto Rican neurosurgeons, we found that for the first 5 search positions, third-party websites were the most commonly encountered website category, followed by hospital, healthcare system, or physician-controlled domains (Figure 2A). In the last 5 search positions, hospital, healthcare system, or physician-controlled websites comprised most of the pages that were encountered, followed by third-party sites.
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Further analysis revealed that 41.5% of the first search results for academic neurosurgeons were hospital, healthcare system, or physician-controlled websites, compared to 25.2% of search results for nonacademic neurosurgeons (Figure 2B). In addition, 55.4% of the first search results for academic neurosurgeons were third-part websites, compared to 72.5% of first search results for nonacademic neurosurgeons. As search position rank decreased (second search result, third search result, and hence) the proportion of social media websites to total search results per search position increased; a similar trend was seen for the proportion of primary academic journal websites to total search results. DISCUSSION This study characterized the online identities of U.S. neurosurgeons through a customized Google search tool and an analysis of a publicly available federal dataset that includes most U.S. physicians. Analysis revealed that most neurosurgeons generally fail to exercise control over their first page of Google search results; a sizable percentage of the top search hits for neurosurgeons pertained to third-party or healthcare institution-controlled websites, as evidenced by a total of 77.0% for all neurosurgeons and 77.1% and 76.9% for academic and nonacademic neurosurgeons, respectively. Compared to academic neurosurgeons, nonacademic neurosurgeons had less control over their online presence. Nonacademic neurosurgeons had a greater percentage of their top 10 search results comprised of third-party websites (42.7% vs 31.9%) as well as a greater percentage of their first search results pertain to a third-party website (72.5% vs 55.4%). These findings are consistent with previous studies that reported a lack of self-controllable content within the top search results for American radiologists15 and radiation oncologists.17
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These findings are particularly alarming given the increasing utilization rates of the Internet as a source for health care and physician information.19
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As there has been a drastic increase in third-party physician websites over the last decade, there has also been an increase in the number of patient ratings and reviews influencing physician ratings. These third-party websites tend to be aggressively marketed and therefore, appear near the top of physician web searches.20-24 Four of the five most commonly encountered domains pertained to third-party physician information websites; these websites (healthgrades.com, health.usnews.com, ucomparehealthcare.com, and vitals.com) combined for a total of 12,781 search results. Healthgrades.com was also the most encountered domain in an online Google search of all radiation oncologists practicing in the U.S.17 It is particularly important that neurosurgeons consider the impact of third-party physician rating websites on their clinical practice. Due to the subspecialized nature of neurosurgery, the number of ratings for a given neurosurgeon is likely to be low, and as a result, even a small number of poor reviews may drastically skew a neurosurgeon's online reputation adversely. With patients increasingly turning to digital platforms to obtain information about physicians, it may not be long before neurosurgeons are 'ranked' by patients in terms of patient outcome, 'fame,' research output, and other similar indicators of physician quality. Thus, neurosurgeons and practice groups may benefit from 'curating' their reviews and profiles on such third-party rating websites to improve and manage their online reputations. To counter the increasing number of third-party rating websites, physicians can build social media profiles. Numerous studies have reported on the use of social media in the field of neurosurgery.25-30 One study reported that the value of social media in neurosurgery could be maximized by utilizing it to facilitate recruitment of patient subjects for clinical trials, thereby reaching numerous potential candidates and educating the general public about the research process.28 Another study identified 158 social media accounts belonging to different neurosurgery departments. Interestingly, while a majority (117) belonged to private rather than academic neurosurgery departments, both groups attained a similar median number of "likes" and "followers," which are two indices of social media presence and popularity.
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Nevertheless, our study identified an overall low social media presence of neurosurgeons with only 2,313 social media hits out of a total of 22,764 search results for academic neurosurgeons and 2,530 social media search results out of a total of 23,111 search results for nonacademic neurosurgeons (Figure 1). The use of social media has been cited to increase physician visibility, to improve physicians’ image in the public domain, and to allow healthcare providers to directly interact with their patients.31,32 Given the potential of a social media presence to improve the visibility of a physician and his/her clinical practice, we suggest that neurosurgeons maintain a significant and controllable online presence through digital platforms.
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This study paints a snapshot of the current limited online presence of neurosurgeons in the United States and Puerto Rico. Most neurosurgeons are visible in online searches, as accounted for by at least one search result being obtained for the entire study population. Nevertheless, the lack of control that neurosurgeons exert over their search results is alarming. To address this issue, there are various ways for neurosurgeons to tailor their digital identities. Neurosurgeons may consult their individual profiles on physician rating websites to evaluate the accuracy of their demographic information (contact information, location, conditions treated). In addition, they can create profiles on professional social media platforms (Doximity.com, Linkedin.com) and 'personal' platforms (Facebook.com, YouTube.com) to improve their social media presence; this may entail implementing personal blogs and/or websites discussing their personal and clinical interests as well as providing pertinent patient education materials. By maintaining control of their digital profiles, neurosurgeons will have the opportunity to better engage with patients and portray the high quality of care that neurosurgeons aim to deliver. Limitations Our study was subject to several important limitations. As previously noted in other studies employing administrative claims data, the study population was limited by self-reporting of physician specialty in the CMS database.15,36,37 In addition, the customized Google search included multiple terms (i.e. [degree] + neurosurgeon + [city] + [state]) which may not fully replicate patients’ actual searches for health care information. Additionally, physicians were flagged as academic neurosurgeons if there was at least one .edu domain within the first 10 search hits for that physician; whether such an approach over or underestimates the number of academic neurosurgeons is difficult to discern.
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There are also certain limitations associated with utilizing a Custom Search Engine (CSE) to obtain physician search results. 17 CSE is the only method publicly available to programmatically query and obtain Google Search results at scale without violating the Terms of Service. However, CSE queries are known to differ slightly from a regular Google search, such as grouping all search results, which would otherwise be separated into the 'web' and 'images' tab of Google search, into one large list.
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In addition, Google Search has been known to alter search results based on previous searches initiated by individuals, in order to provide a 'personalized, tailored' list of search results for individuals. However, the CSE Google searches employed in this study do not take into account these personalized features of a normal search query. As such, the search results obtained in this study for each particular search keyword may not be fully representative of the search results that are obtained by individual patients searching for physicians. Furthermore, this study evaluated the digital identities of all neurosurgeons from the United States and Puerto Rico who participate in Medicare's fee-for-service program. Although these
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two nations have two differing healthcare systems, all such neurosurgeons were included for analysis, as the study population was derived from the CMS database.
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Future Studies This study evaluates the current digital identities of most neurosurgeons practicing in the United States and Puerto Rico. Given the rapidly evolving nature of the Internet and the role of digital resources in everyday life, the need for a future study that re-evaluates the digital identities of neurosurgeons may be warranted. In addition, adjusting for neurosurgeons' ages in evaluating website category distributions of their digital identities may be of interest. Subsequent studies may also assess the online identities of neurosurgeons in other nations.
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CONCLUSION Neurosurgeons lacked a controllable online presence within their first page of Google search results. Third-party physician rating websites accounted for nearly half of the search results, and a relative lack of social media websites was observed. Given the increasing rate at which the Internet is used as a source for health care and physician information, there exist numerous opportunities for neurosurgeons to establish a stronger online presence, such as creating social media accounts representing themselves, or updating and maintaining their profiles on thirdparty physician rating websites.
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FIGURE LEGENDS Figure 1. Frequency of website types in top 10 search results for U.S. neurosurgeons
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Figure 2A. Website types categorized by position within top 10 Google search results for U.S. neurosurgeons Figure 2B. Website types categorized by position within top 10 Google search results for academic and nonacademic U.S. neurosurgeons
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Table 1. Demographics of U.S. and Puerto Rican Neurosurgeons Supplementary Table 1. Examples of Website Categories Supplementary Table 2. Top 10 Domains in the First Page of Google search results for U.S. and Puerto Rico Neurosurgeons
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Characteristic
1902 (40.0) 38 (0.8) 2811 (59.2) 80 (1.7) 349 (7.3) 841 (17.7) 1222 (25.7) 1454 (30.6) 721 (15.2) 84 (1.8)
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Male sex Female sex Degree Type MD DO None listed Graduation Year from Medical School Before 1965 1965-1974 1975-1984 1985-1994 1995-2004 2005-2016 Graduation year not listed
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Total number of U.S. and Puerto Rico neurosurgeons
Value (%)
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Table 1. Demographic Characteristics of U.S. and Puerto Rico Neurosurgeons
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Patients are increasingly turning to the Internet to search for their physicians A demographical analysis of U.S. neurosurgeons' digital profiles was conducted Neurosurgeons' online search results are dominated by third-party and institutional websites The majority of neurosurgeons fail to exercise control over their online identities Neurosurgeons can 'curate' their digital identities to improve patient-provider communication
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CMS: Centers for Medicare and Medicaid Services PCNDF: Physician Comparable Downloadable File
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CSE: Custom Search Engine
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Competing Interests Statement The authors have no personal or institutional interest with regards to the authorship and/or publication of this manuscript.
S1878-8750(18)30253-5
DOI:
10.1016/j.wneu.2018.01.210
Reference:
WNEU 7408
To appear in:
World Neurosurgery
Received Date: 31 December 2017 Revised Date:
29 January 2018
Accepted Date: 30 January 2018
Please cite this article as: Kim C, Gupta R, Shah A, Madill E, Prabhu AV, Agarwal N, Digital Footprint of Neurological Surgeons, World Neurosurgery (2018), doi: 10.1016/j.wneu.2018.01.210. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Digital Footprint of Neurological Surgeons Christopher Kim, B.S.1*, Raghav Gupta, B.S.1*, Aakash Shah, B.S.1, Evan Madill, B.A.2, Arpan V. Prabhu, B.S.3, Nitin Agarwal, M.D.2 1
Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA 3 Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania USA These authors contributed equally
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Funding Statement This study was supported in part by a generous grant from The Beckwith Institute, awarded to Nitin Agarwal, M.D. Competing Interests Statement The authors have no personal, financial, or institutional interest with regards to the authorship and/or publication of this manuscript.
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Contributorship Statement NA, AVP, and RG were involved in the design and conception of this manuscript. NA, AVP, CK, and RG performed the literature search. EM created search tool and collected the data. CK and RG analyzed the data and compiled the tables and figures. CK, RG, and AS wrote the primary manuscript. NA and AVP critically reviewed the manuscript. All authors have approved the manuscript as it is written. Corresponding Author: Nitin Agarwal, M.D. Department of Neurosurgery University of Pittsburgh Medical Center Pittsburgh, Pennsylvania, USA Phone: 908-531-1947 Fax: 412-647-0989 Email: [email protected]
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Running Title: Neurosurgery Digital Footprint ABSTRACT
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Introduction Patients are increasingly turning to online resources to inquire about individual physicians and to gather health information. However, little research exists studying the online presence of neurosurgeons across the country. This study aims to characterize these online profiles and assess the scope of neurosurgeons' digital identities.
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Methods Medicare-participating neurological surgeons from the United States and Puerto Rico were identified using the Centers for Medicare and Medicaid Services (CMS) Physician Comparable Downloadable File. Each physician was characterized by his or her medical education, graduation year, city of practice, gender, and affiliation to an academic institution. Using a Google-based custom search tool, the top ten search results for each physician were extracted and categorized as one of the following: (1) physician, hospital, or healthcare system controlled, (2) third-party or government controlled, (3) social media based, (4) primary journal article, or (5) other.
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Results Amongst the physicians within the CMS database, 4,751 self-identified as being neurosurgeons, yielding a total of 45,875 URL search results pertinent to these physicians. Of the 4,751 neurosurgeons, 2,317 (48.8%) and 2,434 (51.2%) were classified as academic and nonacademic neurosurgeons, respectively. At least one search result was obtained for every physician. Hospital, healthcare system, or physician-controlled websites (18,206; 39.7%) and third-party websites (17,122; 37.3%) were the two most commonly observed domain types. Websites belonging to social media platforms accounted for 4,843 (10.6%) search results, and websites belonging to peer-reviewed academic journals accounted for 1,888 (4.1%) search results. The frequency with which a third-party domain appeared as the first search result was higher for nonacademic neurosurgeons as compared to academic neurosurgeons.
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Conclusions In general, neurosurgeons lacked a controllable online presence within their first page of Google search results. Third-party physician rating websites constituted about half of the search results, and a relative lack of social media websites was apparent. Still numerous opportunities exist for neurosurgeons to address this disparity. Keywords: Online Presence; Neurosurgery; Digital Footprint; Google; Physician Rating Sites; Online Health Care Information
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INTRODUCTION
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The growing accessibility of the Internet has revolutionized the patient-physician relationship and has resulted in online search engines being increasingly used to obtain information about individual healthcare providers.1-11 The accessibility and versatility of online search engines, such as Google, have enabled patients to capture a wealth of information instantaneously.12,13 However, an estimated 91% of patients do not look beyond the first 10 website hits that are obtained.14 In fact, website traffic drops 27% between the first and second website results, alone.14 Given these facts, consideration should be given with respect to the development and maintenance of physicians’ digital or “online” identities.
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In this study, we performed a demographic analysis of U.S. neurosurgeons’ digital profiles via an analysis and categorization of the top 10 Google search results for each provider. We paid attention to differences between academic and non-academic physicians and were careful in discriminating between physician-supported and physician-unsupported websites. As the Internet is a powerful medium by which patients identify and select physicians in an increasingly digital age, we believe the results of this study can serve as a guide for future neurosurgeons and physicians, alike. METHODS Institutional review board approval was not required for this study, as it utilized publicly available federal databases and online data sources. The methods utilized in this study were adapted from those first described by Vijayasarathi et al.15
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Study Population A list of neurosurgeons from the United States and Puerto Rico was obtained from the Centers for Medicare and Medicaid Services (CMS) Physician Comparable Downloadable File (PCNDF),16 which includes self-reported information regarding all physicians who are enrolled in Medicare’s fee-for-service plan, or roughly 90% of all U.S. physicians,15 The database was accessed and de-duplicated on Sept. 23, 2016. All unique entries were included for analysis (n=4,751 Data Collection The list of neurosurgeons was analyzed using Python v2.7 and Pandas, an open-source library dedicated to data manipulation and analysis in Python. Each physician was identified by NPI number, a unique identifier assigned by the PCNDF database. Data parameters mined from the PCNDF database included first name, last name, NPI number, gender, type of degree (MD/DO), medical school graduation year, and the city as well as state of practice. In the case where type of degree was not reported, an MD was assumed. Due to the large number of physicians to be queried, search results for individual physicians were obtained at scale by utilizing a Google Custom Search Engine (CSE), which was programmed in a manner previously reported by
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Prabhu et al17 and Vijayasarathi et al.15 Individual physicians were queried in the following manner: ‘[firstname] + [lastname] + [degree] + neurosurgeon + [city] + [state]’.
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For each neurosurgeon, up to 10 search result URLs were returned. These URLs were saved as a .csv file utilizing the Python Data Analysis Platform and Pandas.18 Neurosurgeons were assigned academic status if at least one of the URLs returned had an .edu address. 45,875 URLs were obtained for the 4,751 neurosurgeons queried. These URLs were arbitrarily divided into 3 groups, and 3 reviewers were assigned to manually classify the domain names of these URLs into one of five predetermined website categories presented in Supplementary Table 1. Each domain was reviewed by at least 2 reviewers; in the case where there was disagreement regarding the classification of a particular domain, a third reviewer was consulted to reach a consensus.
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Data Analysis The number and percentage of search results in each of the 5 website categories were determined; website category frequencies were determined for the academic, nonacademic, and total study population of neurosurgeons. Chi-square analysis was performed to determine if website category frequencies differed significantly between the two study sub-populations (academic and nonacademic). One-way Chi-square analysis was performed to determine if there existed a significant difference between the frequencies of the five website categories in the entire study population. Data analysis was performed with the Prism statistical analysis platform for Mac OS X version 7.0c (GraphPad Software, Inc., San Diego, CA). Significance was defined as p < 0.05.
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RESULTS According to the PCNDF database, 4,751 of the 1,038,373 (0.46%) physicians who participate in Medicare’s fee-for-service plan self-identified as neurosurgeons. Of these physicians, 2,317 (48.8%) and 2,434 (51.2%) identified as academic and nonacademic neurosurgeons, respectively. Additionally, all of the neurosurgeons identified in this study returned at least one Google search result. Demographics of the study population are shown in Table 1.
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Each of the 45,875 domains obtained were categorized into one of five website categories. The top 10 most frequently displayed domains are listed in Supplementary Table 2; the most common website domain was healthgrades.com, with 6,279 search results. Nine of the top 10 most frequently displayed domains were either third-party (5) or social media-controlled (4) websites. There was one primary academic journal website listed among the top 10 domains. Hospital, healthcare system, or physician-controlled websites (18,206; 39.7%) and third-party websites (17,122; 37.3%) were the two most commonly seen website categories within the top 10 search results for each neurosurgeon (Figure 1). Social media websites composed 4,843
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(10.6%) of all search results, and websites classified as 'other' or primary academic journals consisted of 3,816 (8.3%) and 1,888 (4.1%) of all search results, respectively. One-way Chisquare analysis across the entire study population demonstrated that the distribution of website domains across the five website categories was significantly different (p<0.0001). In addition, there was a statistically significant difference between top search results of academic and nonacademic neurosurgeons with regards to the website categories (p<0.0001). Of note, hospital, healthcare system, or physician-controlled websites consisted of 45.2% of the top search results for academic neurosurgeons, compared to 34.2% for their nonacademic counterparts' top search results.
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When an analysis was performed to assess the frequency with which individual website categories were found at each search position within the top 10 Google search results for U.S. and Puerto Rican neurosurgeons, we found that for the first 5 search positions, third-party websites were the most commonly encountered website category, followed by hospital, healthcare system, or physician-controlled domains (Figure 2A). In the last 5 search positions, hospital, healthcare system, or physician-controlled websites comprised most of the pages that were encountered, followed by third-party sites.
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Further analysis revealed that 41.5% of the first search results for academic neurosurgeons were hospital, healthcare system, or physician-controlled websites, compared to 25.2% of search results for nonacademic neurosurgeons (Figure 2B). In addition, 55.4% of the first search results for academic neurosurgeons were third-part websites, compared to 72.5% of first search results for nonacademic neurosurgeons. As search position rank decreased (second search result, third search result, and hence) the proportion of social media websites to total search results per search position increased; a similar trend was seen for the proportion of primary academic journal websites to total search results. DISCUSSION This study characterized the online identities of U.S. neurosurgeons through a customized Google search tool and an analysis of a publicly available federal dataset that includes most U.S. physicians. Analysis revealed that most neurosurgeons generally fail to exercise control over their first page of Google search results; a sizable percentage of the top search hits for neurosurgeons pertained to third-party or healthcare institution-controlled websites, as evidenced by a total of 77.0% for all neurosurgeons and 77.1% and 76.9% for academic and nonacademic neurosurgeons, respectively. Compared to academic neurosurgeons, nonacademic neurosurgeons had less control over their online presence. Nonacademic neurosurgeons had a greater percentage of their top 10 search results comprised of third-party websites (42.7% vs 31.9%) as well as a greater percentage of their first search results pertain to a third-party website (72.5% vs 55.4%). These findings are consistent with previous studies that reported a lack of self-controllable content within the top search results for American radiologists15 and radiation oncologists.17
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These findings are particularly alarming given the increasing utilization rates of the Internet as a source for health care and physician information.19
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As there has been a drastic increase in third-party physician websites over the last decade, there has also been an increase in the number of patient ratings and reviews influencing physician ratings. These third-party websites tend to be aggressively marketed and therefore, appear near the top of physician web searches.20-24 Four of the five most commonly encountered domains pertained to third-party physician information websites; these websites (healthgrades.com, health.usnews.com, ucomparehealthcare.com, and vitals.com) combined for a total of 12,781 search results. Healthgrades.com was also the most encountered domain in an online Google search of all radiation oncologists practicing in the U.S.17 It is particularly important that neurosurgeons consider the impact of third-party physician rating websites on their clinical practice. Due to the subspecialized nature of neurosurgery, the number of ratings for a given neurosurgeon is likely to be low, and as a result, even a small number of poor reviews may drastically skew a neurosurgeon's online reputation adversely. With patients increasingly turning to digital platforms to obtain information about physicians, it may not be long before neurosurgeons are 'ranked' by patients in terms of patient outcome, 'fame,' research output, and other similar indicators of physician quality. Thus, neurosurgeons and practice groups may benefit from 'curating' their reviews and profiles on such third-party rating websites to improve and manage their online reputations. To counter the increasing number of third-party rating websites, physicians can build social media profiles. Numerous studies have reported on the use of social media in the field of neurosurgery.25-30 One study reported that the value of social media in neurosurgery could be maximized by utilizing it to facilitate recruitment of patient subjects for clinical trials, thereby reaching numerous potential candidates and educating the general public about the research process.28 Another study identified 158 social media accounts belonging to different neurosurgery departments. Interestingly, while a majority (117) belonged to private rather than academic neurosurgery departments, both groups attained a similar median number of "likes" and "followers," which are two indices of social media presence and popularity.
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Nevertheless, our study identified an overall low social media presence of neurosurgeons with only 2,313 social media hits out of a total of 22,764 search results for academic neurosurgeons and 2,530 social media search results out of a total of 23,111 search results for nonacademic neurosurgeons (Figure 1). The use of social media has been cited to increase physician visibility, to improve physicians’ image in the public domain, and to allow healthcare providers to directly interact with their patients.31,32 Given the potential of a social media presence to improve the visibility of a physician and his/her clinical practice, we suggest that neurosurgeons maintain a significant and controllable online presence through digital platforms.
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This study paints a snapshot of the current limited online presence of neurosurgeons in the United States and Puerto Rico. Most neurosurgeons are visible in online searches, as accounted for by at least one search result being obtained for the entire study population. Nevertheless, the lack of control that neurosurgeons exert over their search results is alarming. To address this issue, there are various ways for neurosurgeons to tailor their digital identities. Neurosurgeons may consult their individual profiles on physician rating websites to evaluate the accuracy of their demographic information (contact information, location, conditions treated). In addition, they can create profiles on professional social media platforms (Doximity.com, Linkedin.com) and 'personal' platforms (Facebook.com, YouTube.com) to improve their social media presence; this may entail implementing personal blogs and/or websites discussing their personal and clinical interests as well as providing pertinent patient education materials. By maintaining control of their digital profiles, neurosurgeons will have the opportunity to better engage with patients and portray the high quality of care that neurosurgeons aim to deliver. Limitations Our study was subject to several important limitations. As previously noted in other studies employing administrative claims data, the study population was limited by self-reporting of physician specialty in the CMS database.15,36,37 In addition, the customized Google search included multiple terms (i.e. [degree] + neurosurgeon + [city] + [state]) which may not fully replicate patients’ actual searches for health care information. Additionally, physicians were flagged as academic neurosurgeons if there was at least one .edu domain within the first 10 search hits for that physician; whether such an approach over or underestimates the number of academic neurosurgeons is difficult to discern.
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There are also certain limitations associated with utilizing a Custom Search Engine (CSE) to obtain physician search results. 17 CSE is the only method publicly available to programmatically query and obtain Google Search results at scale without violating the Terms of Service. However, CSE queries are known to differ slightly from a regular Google search, such as grouping all search results, which would otherwise be separated into the 'web' and 'images' tab of Google search, into one large list.
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In addition, Google Search has been known to alter search results based on previous searches initiated by individuals, in order to provide a 'personalized, tailored' list of search results for individuals. However, the CSE Google searches employed in this study do not take into account these personalized features of a normal search query. As such, the search results obtained in this study for each particular search keyword may not be fully representative of the search results that are obtained by individual patients searching for physicians. Furthermore, this study evaluated the digital identities of all neurosurgeons from the United States and Puerto Rico who participate in Medicare's fee-for-service program. Although these
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two nations have two differing healthcare systems, all such neurosurgeons were included for analysis, as the study population was derived from the CMS database.
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Future Studies This study evaluates the current digital identities of most neurosurgeons practicing in the United States and Puerto Rico. Given the rapidly evolving nature of the Internet and the role of digital resources in everyday life, the need for a future study that re-evaluates the digital identities of neurosurgeons may be warranted. In addition, adjusting for neurosurgeons' ages in evaluating website category distributions of their digital identities may be of interest. Subsequent studies may also assess the online identities of neurosurgeons in other nations.
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CONCLUSION Neurosurgeons lacked a controllable online presence within their first page of Google search results. Third-party physician rating websites accounted for nearly half of the search results, and a relative lack of social media websites was observed. Given the increasing rate at which the Internet is used as a source for health care and physician information, there exist numerous opportunities for neurosurgeons to establish a stronger online presence, such as creating social media accounts representing themselves, or updating and maintaining their profiles on thirdparty physician rating websites.
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FIGURE LEGENDS Figure 1. Frequency of website types in top 10 search results for U.S. neurosurgeons
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Figure 2A. Website types categorized by position within top 10 Google search results for U.S. neurosurgeons Figure 2B. Website types categorized by position within top 10 Google search results for academic and nonacademic U.S. neurosurgeons
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Table 1. Demographics of U.S. and Puerto Rican Neurosurgeons Supplementary Table 1. Examples of Website Categories Supplementary Table 2. Top 10 Domains in the First Page of Google search results for U.S. and Puerto Rico Neurosurgeons
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Characteristic
1902 (40.0) 38 (0.8) 2811 (59.2) 80 (1.7) 349 (7.3) 841 (17.7) 1222 (25.7) 1454 (30.6) 721 (15.2) 84 (1.8)
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Male sex Female sex Degree Type MD DO None listed Graduation Year from Medical School Before 1965 1965-1974 1975-1984 1985-1994 1995-2004 2005-2016 Graduation year not listed
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Total number of U.S. and Puerto Rico neurosurgeons
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Table 1. Demographic Characteristics of U.S. and Puerto Rico Neurosurgeons
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Patients are increasingly turning to the Internet to search for their physicians A demographical analysis of U.S. neurosurgeons' digital profiles was conducted Neurosurgeons' online search results are dominated by third-party and institutional websites The majority of neurosurgeons fail to exercise control over their online identities Neurosurgeons can 'curate' their digital identities to improve patient-provider communication
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CMS: Centers for Medicare and Medicaid Services PCNDF: Physician Comparable Downloadable File
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CSE: Custom Search Engine
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Competing Interests Statement The authors have no personal or institutional interest with regards to the authorship and/or publication of this manuscript.