Consumers’ Attitudes toward Advertising by Physicians

H. Ronald Moser
Middle Tennessee State University

Introduction

General Overview
     For the health professions, marketing has traditionally been a controversial issue. The notion of using advertising to promote a professional’s practice is new and, to many, even startling. Many professionals find themselves ill equipped to handle the dynamics of a changing environment, especially without some form of ongoing marketing plan. Most professional societies and associations have prohibited the marketing of their services, mainly because they considered themselves to be above the mainstream of the competitive marketplace (Wright, Raho, and Berkowits, 1989; Duffus, 1990).
     In 1975, the Federal Trade Commission (FTC) began an investigation into anticompetitive practices in the health care profession (American Medical Association v. FTC 1980-1982). A Federal Trade Commission (FTC) administrative law judge issued a decision that the American Medical Association (AMA) has caused substantial injury to the public by restricting advertising and other business practices of physicians. The decision says there is no doubt the AMA has made substantial contributions toward improving the nation’s health care but that its restriction on advertising “serves to deprive consumers of the free flow of information about the availability of health care services,” has deterred “the offering of innovative forms of health care,” and has “stifled the use of almost every type of health care delivery that would potentially pose a threat to the incomes of fee-for-service physicians in private practice” (FTC Judge, 1978).
     Alfred F. Dougherty, Jr., deputy director of the FTC’s Bureau of Competition, said the trade commission complaint against the AMA was not designed to force doctors to advertise if they choose not to. All the commission desired was to change the AMA’s code of ethics to permit enough advertising to give patients “a decisional basis for selecting one doctor as opposed to another” (Nicholson, 1976).

Purposes of the Study

     During the past several years, physicians have become highly competitive in marketing their services to the public, and it has become common for physicians to advertise their services using a variety of media.
     The purposes of this study were to determine (a) consumers’ attitudes toward advertising by physicians; (b) which media consumers feel are appropriate for physicians’ advertising; and (c) whether consumers are aware of physicians’ advertising, and if so, through which media. It was the intent of this study to discover information that would be useful to physicians in planning and improving the quality of their advertising.

Background and General Research Questions

     Commercial speech, e.g., business and professional advertising, has not always enjoyed First Amendment protection. Furthermore, most professional associations (ABA, AMA, etc.) traditionally explicitly prohibited licensed members from engaging in advertising their services to the public (Kershen, 1999; Altman, 2003). Such proscriptions were usually upheld by the courts, whose longstanding legal position was clearly enunciated in an early decision by the U.S. Supreme Court (Valentine, 1942). There the Court ruled that the First Amendment did not impose restraints on government regulation of commercial advertising. The Supreme Court did not critically reexamine this position for more than 30 years. Then, in 1975, the Court held that the “relationship of speech to the marketplace of products or of services does not make it valueless in the marketplace of ideas” (Bigelow, 1975).
     One year later the Court clearly reaffirmed the new First Amendment protection for commercial speech. In 1976, the Court struck down a state statute that prohibited licensed pharmacists from advertising prices of prescription drugs, stating that even if an advertiser’s interest is “a purely economic one, that hardly disqualifies him from protection under the First Amendment” (Virginia State Board of Pharmacy, 1976).
     The following year the Court recognized that practicing health care services was both a profession and a business and, in order to survive in a changing and competitive environment, health care providers had to adopt modern business practices. These practices would include advertising for new patients (Endresen and Wintz, 2002). This was when the Court established the bedrock foundation for the constitutional protection of physicians’ advertising. The Court was asked to decide whether a “state may prevent the publication in a newspaper of appellant’s truthful advertisement concerning the availability and terms of routine legal and health care services” (Bates, 1977). In response, the Court held that “blanket suppression of health care advertising…does abridge First Amendment rights” (Bates, 1977). In Bates and other decisions, the Court has recognized that a state has a “substantial interest” in professional and health care advertising and may impose “reasonable restrictions on the time, place, and manner of advertising” (Martel, 1997).
     During the 29 years since Bates was decided, courts have often reviewed the issue of constitutional protection for professionals who advertise. The cases have addressed such issues as the solicitation of patients in person, listing of professional practice specialties on letterheads, use of illustrations/pictures in ads, and use of targeted direct-mail solicitations. A review of these cases demonstrates that, while the courts have permitted some state limitations on physicians’ advertising, the right of health care professionals to engage in truthful non-deceptive commercial advertising has consistently been upheld (Ohralik, 1978; In re R.M.J., 1982; Zauderer, 1985; Shapero, 1988; Peel, 1990; Florida Bar, 1995).
     During this time the business practices of health care professionals have undergone many changes. Consumers are becoming more involved in their own health care and are willing to take more responsibility to obtain adequate treatments than in the past (Handlin, Mosca, Forgione, and Pitta, 2003). Another change is the frequent use of advertising. Today it is fairly common in most parts of the country for people to see one of the many thousands of physicians’ advertisements shown on television every day, receive a spam e-mail advertisement from a physician, view one of the many hundreds of yellow page physicians’ ads while using the phone book, or even see some of the hundreds of highway billboards promoting a hospital’s or physician’s services that are permitted in some areas of the nation (Carabello, 2003). A marketing budget has become critical for most medical practices. Many health care and legal professionals now use marketing consulting firms or have their own internal marketing/advertising committees (Sahl, 2003).
     According to a study by Butler and Abernethy (1996), yellow page ads have been the most popular form of health care professional advertising. This study revealed that every month approximately 21.6 million adults in the United States refer to the yellow pages before obtaining medical care (Butler and Abernethy, 1996), although a study conducted by Reade and Ratzan in 1987 revealed that yellow pages are potentially misleading to consumers and that member boards of the American Board of Medical Specialties should consider ways to diminish this possible misrepresentation (Reade and Ratzan, 1987). Such ads are now the top revenue category for the yellow pages phone directory with professionals such as lawyers and physicians spending more than $700 million annually to be listed. In the year 2000, these professionals spent $230 million on television advertising just in the nation’s top 75 TV markets (Freedman, 2001).
     While the attitude of health care professionals toward advertising is mixed and the attitude of most state regulators has generally been negative, the attitude of consumers has historically been fairly positive (Hekmat and Heischmidt, 1991). Since professional advertising became commonplace after the Bates decision, there have been many professional-association sponsored and academic studies designed to measure consumers’ and health care providers’ attitudes toward advertising. The results of a study conducted by Moncrief and Bush (1988) revealed that consumers felt advertising by professionals was somewhat helpful in making a decision about health care providers (Moncrief and Bush, 1988).
     The concern of practicing health care professionals, whether advertising by physicians attracts new patients, has been the focus of several academic studies. The answer has been a definite “yes.” These studies show most physicians who advertise will likely see an increase in the number of middle- to lower-income patients. Physicians who advertise discover quickly that advertising is usually very expensive, but if it is done properly and ethically, it works. One study found that the return on dollars invested by professionals in advertising was four to six times the cost (Freedman, 2001).
     The above discussion shows that professional advertising usually works, produces an increase in patient flow, yields a good return on physicians’ advertising dollars, and is found to be protected by the First Amendment. It shows that historically consumers have not always had a positive view of physicians who advertise but believe physicians’ advertisements provide useful information.
     This study includes items that explore opinions regarding the informational function of, importance of price in, deception in, future of, and appropriate media for physicians’ advertising.
     Specifically, the study examines attitudes concerning whether physician advertising would (1) provide useful information to the public, (2) increase the costs of health care services, (3) increase the quality of physicians’ services in the future, (4) help consumers make more intelligent choices between physicians, (5) tend to lower the credibility and dignity of their services, and (6) make the public more aware of the qualifications of physicians.

Methodology

Data Collection
     Much of the initial planning of this study was based on Hite’s study at the University of Arkansas (Hite, 1982). Acknowledgement is given to Hite’s research instrument as well as to the instrument of Miller and Waller (1979), which served as bases for the questionnaire in the current study. Also, acknowledgment is given to the organization and writing style of Hite’s study, which served as a model for this paper.
     A four-part questionnaire was used to collect the data. The first section concerned demographic characteristics of the respondents: city of residence, occupation, age, sex, race, marital status, number of children in household, total family household income, and education. The second section of the questionnaire included 19 statements designed to measure how favorably consumers perceived advertising by physicians. The respondents were asked to assess the strength of their agreement with the statements on a scale ranging from “strongly agree” to “strongly disagree.” Table 1 contains these 19 statements.
     The third section of the questionnaire listed 10 different media that physicians could use to advertise their services. The respondents were asked how appropriate each medium was for physicians’ advertising. The responses ranged from “very appropriate” to “very inappropriate.” Table 2 contains the data captured by this section of the questionnaire.
     The fourth section asked the respondents whether they had ever seen physicians advertise and, if so, through which media. Tables 3 and 4 contain the data captured by this section. The researcher asked the Marketing System Group to draw a random sample of 4,000 consumers as of July 2006 from the seven metropolitan statistical areas in Tennessee: Memphis, Nashville, Clarksville, Chattanooga, Knoxville, Jackson, and the Tri-Cities (Bristol, Kingsport, and Johnson City). Appropriate numbers from each city were drawn according to the percentage of the population of each city in relation to the total population of all seven urban areas. The research instrument was mailed to those consumers, and 411 usable questionnaires were received and used in this study.
Demographic Variables
     The 411 participants included 218 males and 188 females (missing data = 5). Regarding age, 6 (1.5 percent) were 18-25, 35 (8.6 percent) were 26-35, 57 (14 percent) were 36-45, 98 (24.1 percent) were 46-55, and 213 (52 percent) were 56 or older. The majority were white (86.6 percent). In terms of marital status, 52 (12.7 percent) were single, 262 (63.7 percent) were married, 51 (12.5 percent) were divorced, 37 (9.1 percent) were widowed, and 6 (1.4 percent) were separated. Further, 18 (4.4 percent) had less than a high school education, 67 (16.5 percent) were high school graduates, 109 (27 percent) had some college education, 112 (27.7 percent) were college graduates, and 99 (24.4 percent) had advanced degrees. Moreover, 64 were professional, and 344 were nonprofessional. Regarding total family household income, 20 (5.2 percent) had $15,000 or less, 42 (11 percent) had $15,001-30,000, 72 (18.8 percent) had $30,001-45,000, 70 (18.3 percent) had $45,001-60,000, and 178 (45.6 percent) had more than $60,000. Participants in the present study were mostly white, male, age 56 or older, and married. They also had college education and high income. Thereby, participants in this sample do not match the population perfectly. However, there was no reason to believe this sample was atypical.

Findings

     The data obtained from the 411 respondents via the research instrument were analyzed by tabulating the frequency percentages for each item on the questionnaire.
Consumer Attitudes toward Advertising Physicians’ Services
     The percentages given in Table 1 illustrate the distribution of consumer responses to the 19 statements in the questionnaire toward physicians with respect to advertising.
     With regard to statement 9, 66.4 percent agreed they presently have a high image of physicians, 14.1 percent had no opinion, and 19 percent did not have a high image. In general, consumers indicated a somewhat favorable image of physicians.
     In response to statement 10, opinions were rather mixed. More than 42.0 percent of consumers agreed that their opinion of physicians would be lowered as a result of advertising, 37.4 percent disagreed (4.6 percent strongly disagreeing), and 20.2 percent had no opinion. The percentage of respondents who agreed it is proper for physicians to advertise was 35.3 percent (statement 4), while 34.3 percent disagreed. Further, 40.3 percent agreed with statement 15 that advertising would lower the credibility and dignity of services by physicians. However, 39.6 percent of the respondents disagreed. Finally, when asked (statement 19) if they would use the services of physicians who advertise, 52.0 percent expressed agreement, while only 19.5 percent said they would not use these services. These results indicate that consumers’ image of physicians generally does not suffer as a result of advertising.
Information Function of Advertising Physicians’ Services
     Opinions are somewhat mixed in this area. The results show that 41.6 percent of respondents disagreed while 36.5 percent agreed with statement 1 that the public would be provided useful information through advertising by physicians. Also, 58.1 percent felt that physicians’ advertising would be a useful means of informing potential patients about services and specialties (statement 5). However, 46.0 percent disagreed and 40.1 percent agreed with statement 16 that advertising makes the public more aware of the qualifications of physicians. Finally, 50.3 percent disagreed with statement 11 that advertising would not help consumers make more intelligent choices between physicians, while 30.9 percent agreed.
Importance of Price in Advertising Physicians’ Services
     In response to statement 7 that it is good to deal with physicians who offer the lowest price for routine services, 55.7 percent disagreed, 19.5 percent were undecided, and 24.5 percent agreed. However, 85.7 percent agreed that it is better to deal with a reputable physician than one who offers the lowest price (statement 18). With regard to the effect on prices as a result of physicians’ advertising, 65.9 percent of respondents disagreed with the statement (number 13) that physicians’ advertising lowers prices due to more competition. Consumers also believed (78.1 percent) that prices were increased rather than lowered because of the costs of advertising (statement 2). It would appear the primary benefit of physicians’ advertising is not the communication of price information but providing information regarding health care services. The respondents also indicated that the reputation, image, and qualifications of the physician are more important than specific price information.
Deception in Advertising Physicians’ Services
     In response to statement 6 that advertising by physicians would be more deceptive than other forms of advertising, 51.1 percent expressed disagreement, while only 20.7 percent agreed. Also, 43.8 percent of the respondents disagreed with statement 12 that they would be suspicious of physicians who advertise. And finally, 56.3 percent disagreed with statement 17 that advertising by physicians would primarily benefit quacks and incompetents. Consumers agreed (83.2 percent), however, with statement 8 that people can rely more on what friends tell them about physicians than on advertising. The responses indicate consumers feel that the image or reputation of physicians is more important than specific price information. These results indicate that, in general, consumers do not view physicians’ advertising as being more deceptive than other forms of advertising.
The Future of Physicians’ Advertising
     When asked whether they would like to see more advertising by physicians (statement 14), 57.6 percent of the respondents disagreed, 19.2 percent agreed, and 22.6 percent were undecided. In addition, a majority of respondents (65.7 percent to 14.4 percent) did not feel advertising would increase the quality of physicians’ services in the future (statement 3).
Appropriateness of Advertising Media for Physicians
     The results in Table 2 indicate that 87.6 percent of the respondents felt that the yellow pages are an appropriate medium for physicians who advertise (33.3 percent said “very appropriate”). Professional magazines were second with a 76.9 percent rating as appropriate (21.7 percent said “very appropriate”). Third were newspapers with 58.2 percent considering them an appropriate medium for physicians.
However, in this case, 28 percent of those consumers who responded felt that newspapers are not an appropriate medium.
     On the other hand, 86.1 percent of the respondents felt that the telephone is an inappropriate advertising medium for physicians (47.4 percent said “very inappropriate”). Also, 59.2 percent consider billboards to be inappropriate (22.9 percent said “very inappropriate”). Third was direct mail: 49.4 percent felt this medium is inappropriate for physicians (22.1 percent said “very inappropriate”). Television was fourth: 45.0 percent felt that it is inappropriate (17.0 percent said “very inappropriate”). Fifth was radio: 43.6 percent of those who responded felt it to be inappropriate (14.4 percent said “very inappropriate”).
     Opinions were mixed regarding advertising over the Internet and in popular magazines. As Table 2 indicates, 44.5 percent felt the Internet is appropriate, and 37.0 percent felt it is inappropriate. A majority of respondents felt that advertising in popular magazines is appropriate for physicians (44.3 percent); however, 38.04 percent felt it is inappropriate.
Exposure to Advertising by Physicians
     One factor that should be considered is the degree to which the respondents have been exposed to physicians’ advertising. In Section IV of the questionnaire, respondents were asked whether they had ever seen advertising by physicians and, if so, to indicate the media used. Respondents could indicate more than one advertising vehicle.
     As Table 3 indicates, 316 respondents or 76.9 percent had seen at least one physician’s advertisement, while only 94 or 22.9 percent could not recall seeing any advertising by physicians.
     Table 4 indicates that the highest percentage of those respondents who had seen physicians advertise, 56.7 percent, had viewed an advertisement in the yellow pages. Second was television, with 47.9 percent of respondents who had seen physicians’ ads recalling at least one advertisement on television. In third place were newspapers with 44.8 percent, and in fourth place billboards with 29.0 percent. Radio was fifth with 26.0 percent. Sixth was direct mail with 21.2 percent. Seventh and eighth were professional magazines and Internet with 20.0 and 10.2 percent, respectively. Ninth and tenth were popular magazines, 8.5 percent, and telephone, 2.4 percent.

Conclusion

     The results of this study have a number of implications. First, although consumers’ opinions about advertising by physicians are mixed, they look for and generally favor advertising as a means of obtaining some kinds of information about health care services. The results in Table 1 indicate that consumers expressed a favorable response (i.e., more than 50 percent) toward physicians’ advertising on items 2, 5, 8, 9, 18, and 19. Consumers desire more information about the services of physicians and feel that advertising by physicians could help them learn about services and specialties of particular physicians. Physicians and other health care providers should be informed of these and similar survey results so they can begin to satisfy the health care needs and desires of the public. However, it is interesting to note that, as indicated in Table 1, only 19.2 percent of respondents wanted to see more advertising by physicians, while 57.6 percent did not wish to see more advertising, and 22.6 percent were undecided.
     Second, opinion leaders among the health care industry should be encouraged to use informational advertising. Much has been written about the ethical implications of advertising by professionals and the attitudes of those professionals who must make the decision whether to advertise or not. Although many physicians have indicated they would not advertise even if others did, it is likely that some of these physicians could be encouraged to try advertising if they were convinced it could be done tastefully and for the purpose of informing and serving the community.
     Third, since most physicians have little or no professional training in advertising, it will be increasingly important to involve them in educational programs that focus on advertising health care services in order to help them identify the most appropriate media for advertising. As indicated in Table 2, the researcher tried to determine which media consumers believed were appropriate for physicians’ advertising. It is not surprising that respondents to the survey indicated yellow pages are the most appropriate medium. An overwhelming majority (87.6 percent) responded favorably to the use of yellow pages. Respondents selected professional magazines as the second most appropriate medium with a 76.9 percent approval rate. Newspapers also received appropriate ratings from more than 50 percent of the respondents. Media rated least appropriate by respondents were telephone (86.1 percent), billboards (59.2 percent), and direct mail (49.4 percent).
     The results shown in Tables 3 and 4 indicate the vast majority of consumers have seen physicians advertise, and of those who have, most have noticed advertisements in the yellow pages and on television.
     The study seems to confirm the belief of many marketing professionals that advertising is clearly an important function in the management and operation of a medical practice. Physicians could find that a well-conceived, professionally designed advertising program as a means of communicating useful information could help gain the approval of the majority of consumers. With this in mind, leaders in the medical profession should be encouraged to support informational advertising.

Table 1
Frequency Percentages of Consumer Responses toward Attitude Statements
(in Percent) for Physicians                                                                                                                                                ______________________________________________________________________________
                 Strongly        Agree       Undecided        Disagree          Strongly
                  Agree                                                                        Disagree
______________________________________________________________________________

  1. The public would be provided                       5.8           30.7            21.7               26.8                 14.8                 
       useful information through                                                                                                                                  
       advertising by physicians.  
                                                                                                               
  2.  When physicians advertise,                      34.3           43.8            12.7                 5.4                  3.6
        the costs are passed on to
        their patients through                                                                                                                    
        higher prices.

  3.  Advertising will increase                             4.9            9.5            19.5               38.7                 27.0
       the quality of physicians’                                                                                                                              
       services in the future.

  4.  It is proper for physicians                           5.6           29.7             29.4              20.9                 13.4
       to advertise.

  5.  Advertising by physicians                         10.2           47.9           14.6                19.7                  6.8     
       would be a useful means of
       informing potential patients
       about services and specialties.

  6.  Advertising by physicians                          4.4            16.3            27.7               44.0                  7.1        
       would be more deceptive than
       other forms of advertising.

  7.  It is good to deal with                                 8.0          16.5             19.5              42.1                 13.6
       physicians who offer the                                                                                                            
       lowest prices for routine                                                                                                                         
       services.

  8.  You generally can rely more                      29.9          53.3              9.2                5.6                   1.2
       on what a friend tells you  
       about physicians than on                                                                                                              
       advertising.

  9.  I presently have a high image                      7.3          59.1            14.1              16.1                    2.9
       of physicians.
                                                          
10.  In general, my image of                             10.0          32.1            20.2              32.8                   4.6                
       physicians would be lower as
       a result of their advertising.

11.  Advertising would help                                5.1           25.8           18.5               38.4                 11.9
       consumers make more
       intelligent choices among                                                                                                                  
       physicians.
 
12.  I would be suspicious of                              9.5          29.7            16.8               37.0                  6.8
       physicians who advertise.

13.  When physicians advertise,                        1.5            8.5             23.4                47.9               18.0
       prices are lowered due to                                                                                                                  
       more competition.

14.  I would like to see more                              2.4          16.8            22.6                35.5                22.1
       advertising by physicians.

15.  Advertising by physicians                           9.2           31.1            19.5               33.8                  5.8
       would tend to lesson the
       credibility and dignity of                                                                                                               
       their services.

16.  Advertising makes the                               4.6            35.5            13.6               37.0                  9.0          
       public more aware of the
       qualifications of physicians.

17.  Advertising by physicians                           4.9           15.8            21.7               43.6                 12.7
       would benefit only quacks 
       and incompetents.

18.  It is better to deal with                              37.5           48.2             7.8                 4.9                  1.5
       reputable physicians rather                                                                                                                   
       than with one who offers                                                                   
       the lowest prices.                                                                                                          
     
19.  I would use the services                             6.3           45.7            28.2               14.6                  4.9
       (if needed) of physicians                                                                                                                 
       who advertise.

Table 2
Appropriateness of Advertising Media for Physicians Who Advertise
_______________________________________________________________________

                                           Very                                                                                 Very            
                                           Appro-           Appro-             Unde-             Inappro-          Inappro-       
     Media                             priate             priate              cided               priate              priate
______________________________________________________________________________________________

Table 3
Consumer Exposure to Advertising by Physicians
______________________________________________________________________________________
Exposure Level of the Sample                                                             Number               Percent
______________________________________________________________________________________ 
  Respondents who had seen physicians advertise                                    316                        76.9 
                  
Respondents who had not seen physicians advertise                               94                        22.9
______________________________________________________________________________________
 

Table 4
Advertising Media Utilized by Physicians (as reported by 316 respondents
who had seen physicians advertise)

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