The Utility of Telemedicine in Plastic and Reconstructive Surgery: Provider and Patient Perspectives

Telemedicine is a promising innovation that allows for remote communication between the clinician and patient. When used appropriately, telemedicine visits can improve accessibility and efficiency as well as reduce costs.^1-4 Telemedicine has proven particularly useful since the COVID-19 pandemic,^5,6 during which social distancing measures and hospital visitor restrictions limited the ability of clinicians to hold in-person clinic visits. In the field of plastic surgery, telemedicine can be applied to a variety of different subspecialties and used for various purposes, such as new patient consults, preoperative planning, or postoperative follow-up. 

Despite the growing utility of telemedicine in surgery, it also holds certain disadvantages. For both the clinician and the patient, telemedicine technology can be difficult to implement and utilize. For new patient consults or preoperative planning, many clinicians find it difficult, if not impossible, to formulate a surgical plan without performing a physical examination. Certain patient populations, such as those undergoing breast procedures, may also experience an increased level of discomfort with exposing sensitive areas via video or photo sharing. 

To date, several studies have investigated the use of telemedicine in plastic surgery. Overall, a majority of plastic surgery patients have been found to be comfortable with the use of telemedicine.¹ Telemedicine has also been shown to improve postoperative monitoring, provide increased access for patients in rural areas, and significantly reduce costs.⁷ However, many existing studies have been limited to only a single area within the field of plastic surgery, such as wound care or free flap monitoring.^8,9 Furthermore, few studies have surveyed clinicians to better understand their comfort level and satisfaction with the use of telemedicine. 

As telemedicine continues to become more ubiquitous, it is important to gain a better understanding of its practicality and utility. The purpose of this study was to survey both providers and patients to assess how telemedicine is being used across multiple plastic surgery subspecialties, the perceived advantages and disadvantages of telemedicine visits, and overall satisfaction with telemedicine visits from the perspective of both the provider and patient.

To better understand the use of telemedicine in plastic surgery, a survey was derived from the Telehealth Usability Questionnaire (TUQ). The TUQ is a validated and reliable instrument used to measure the quality of telehealth services and interactions.¹⁰ For this study’s purposes, the TUQ was modified to apply to the field of plastic surgery and be usable for both patients and providers. In addition to basic demographic data, the survey also included questions regarding distance between one’s home and medical facility, average time spent per telemedicine visit, and other pertinent variables of interest (see Appendices A and B). 

Following institutional review board approval, the patient survey was distributed via email to all patients who had telemedicine visits with the division of plastic and reconstructive surgery at the authors’ institution from April to October 2020. The provider survey was distributed via email through the American Society of Plastic Surgeons (ASPS) to a representative cohort of ASPS members. A total of 501 patients and 2701 providers were invited to participate. 

After data collection, all statistical analyses were performed using SPSS v26 (IBM Corp). Basic descriptive statistics were used to summarize demographic data. Independent t tests were used to compare means between groups, and chi-square tests were used to compare categorical variables. Patient and provider responses to the Likert scale survey questions were compared using the Mann-Whitney (U) test. For all tests, P values less than .05 were considered statistically significant. 

A total of 67 participants responded to the patient survey (N = 501; 13.4% response rate) and 160 (N = 2701; 5.9%) responded to the provider survey. Providers were significantly older than the patient respondents (55.0 ± 11.6 vs 45.8 ± 11.8 years; P < .001). There were also significant differences between patients and providers with regards to gender (P < .001), race (P < .001) and Hispanic, Latino, or Spanish origin ethnicity (P = .012; Figure 1). Most patient respondents had a 4-year degree (n = 25; 37.3%) and earned a salary greater than $90,000 USD (n = 26; 38.8%). A majority of providers practiced in the southern (n = 61; 38.1%) or western (n = 52; 32.5%) US, with the remaining 15.6% in the Midwest (n = 25) and 13.8% in the Northeast (n = 22). 

Most providers held MD or DO degrees (n = 158; 98.8%), while 2 respondents (1.3%) self-reported their qualifications as “other.” In describing their practice type, providers most commonly reported they worked in a solo practice (n = 75; 46.9%; Figure 2). In terms of time spent in their practice, 48 respondents (30.0%) reported that 100% of their case load was cosmetic procedures. Cosmetic surgery was also the most commonly reported subspecialty (n = 108; 67.5%). Providers most frequently stated that they billed for a telemedicine visit at the same rate as an in-person visit (n = 66; 41.3%). Most providers stated that they used another telemedicine service other than one of the options listed (n = 56; 35.0%), followed by Zoom (n = 42; 27.8%), Doximity (n = 21; 13.1%), FaceTime (n = 12; 7.5%), Epic (n = 10; 6.3%), Vidyo (n = 6; 3.8%), Modmed (n = 2; 1.3%), and Klara (n = 2; 1.3%); 5.6% (n = 9) did not respond. 

Patients and providers reported similar values for the average duration of a telemedicine visit (17.6 ± 14.4 vs 19.3 ± 11.9 minutes, respectively; P = .392). Most patients and providers lived within 5 to 20 miles from the plastic surgeon’s primary place of practice, with an average travel time of 5 to 20 minutes (Figure 3). However, between patients and providers, there were significant differences in the overall distribution of distance to the office, both in terms of miles (P = .001) and travel time (P < .001).  

Patients responded significantly more favorably than providers to the majority of survey questions within the domains of telemedicine usefulness, ease of use, interaction quality, and reliability. Within the domain of satisfaction and future use, patient and provider responses were statistically similar with regards to comfort level in using telemedicine for preoperative, postoperative, new patient, and return visits. When asked to rate their comfort level with using telemedicine to undergo/perform a physical examination, patients responded significantly more favorably than providers for all body parts listed. Full results of the Likert survey questions are displayed in Figure 4.  

In recent years, telemedicine has become an increasingly popular patient care tool used throughout various medical specialties. This became especially true during the COVID-19 pandemic as telemedicine provided a means for providers and patients to interact while maintaining social distance. Telemedicine has the ability to improve access and reduce costs, potentially leading to an overall improvement in quality of care. Despite these notable advantages, however, telemedicine visits have certain disadvantages compared with traditional in-person visits, such as the inability to perform a full physical examination, discomfort with exposing certain body parts on camera, and various technological difficulties. 

Several recent reports have examined the use of telemedicine in plastic and reconstructive surgery. The benefits of telemedicine have been lauded in a variety of subspecialties, including breast, wound care, and gender affirmation surgery.^8,11-13 In a survey of patients who had undergone plastic surgery procedures, Funderburk found patients generally preferred in-person follow-up visits but were overall satisfied with the telemedicine system implemented by the authors’ institution.¹ Calderon et al surveyed plastic surgeons throughout the US and found surgeons believed telemedicine allowed them to meet their care goals and establish rapport with the patient.¹⁴ Plastic surgeons increasingly recognized the benefits of telemedicine during the COVID-19 pandemic as well.^14-17 In 2020, the Coronavirus Preparedness and Response Supplemental Appropriations Act eased restrictions on the use of telemedicine, leading to increased reimbursements from both Medicare/Medicaid and private insurance companies.⁵

Although these surveys provide valuable understanding of the use of telemedicine, they were primarily written from the perspective of the provider. The health care needs of patients and providers are often very different, and therefore the utility, comfort level, and satisfaction with telemedicine may vary considerably between these two groups. In a recent study by Brown-Johnson et al, both patients and providers were interviewed on their use of telemedicine; however, the interviews were qualitative in nature, and the study’s sample size was relatively small (20 patients, 10 providers).¹⁸ 

To the author’s knowledge, the current study is the first to collect quantitative data comparing patient and provider use and attitudes towards telemedicine specifically in the field of in plastic surgery. A total of 227 participants responded to the survey, including 67 patients and 160 providers. Providers were statistically older than patient respondents, and there were significant differences between the two groups with regard to gender, race, ethnicity, and travel distance from home to the provider’s office. Most providers worked in a solo practice dedicated exclusively to cosmetic surgery. 

Patients responded more positively than providers to nearly all questions within the domains of usefulness, ease of use, interaction quality, and reliability. Patients consistently found telemedicine to be more useful than providers, with higher responses to “Telemedicine improves my ability to provide/access healthcare services” (3.97 ± 1.15 vs 3.49 ± 1.15; P = .001) and “Telemedicine provides for my healthcare need” (3.58 ± 1.30 vs 3.18 ± 1.15; P = .016). Patients were also more likely to state telemedicine saved time traveling to a hospital or clinic (4.20 ± 1.00 vs 2.85 ± 1.29; P < .001), which coincides with the statistical differences between patients and providers with regard to distance from home to the clinician’s place of practice (miles to primary place of practice, P = .001; minutes to primary place of practice, P < .001). Compared with providers, patients also found telemedicine systems to be easier to learn, easier to use, more reliable, and of higher quality interaction. These results signify that patients generally find telemedicine to be a valuable tool for accessing health care, and providers should be open to providing telemedicine options for their patients.  

Within the domain of satisfaction and future use, patients were more comfortable than providers with communicating via telemedicine (4.20 ± 0.95 vs 3.75 ± 1.04; P = .001). Patients were more comfortable scheduling a surgery before an in-person visit (3.21 ± 1.45 vs 2.34 ± 1.23; P < .001); however, there were no differences between patient and provider comfort levels regarding the use of telemedicine for preoperative, postoperative, new patient, or return visits. Provider’s lack of comfort in scheduling surgery before an in-person visit likely stems from the inability to perform a thorough physical examination, take measurements, and/or establish a face-to-face rapport with the patient. Other visit types, such as postoperative or return visits, are generally less extensive or time-consuming, which may explain providers’ relative satisfaction with conducting these visits virtually. 

Patients were significantly more comfortable undergoing a physical examination via telemedicine than providers were with performing such an examination (3.73 ± 1.36 vs 2.39 ± 1.17; P < .001). This is congruent with the fact that patients rated higher comfort levels than providers with a physical examination of every body part listed in the survey. However, comfort levels with sensitive areas, such as breast/chest (patients 3.35 ± 1.26, providers 2.41 ± 1.13) and genitals (patients 2.79 ± 1.27, providers 1.96 ± 1.00), were relatively low for both groups. These data emphasize the importance of an in-depth discussion between the patient and provider to gauge patient comfort and establish boundaries before a virtual physical examination. 

Overall, the authors believe the data presented in this study provide valuable understanding of the utility of telemedicine in plastic surgery. This study is the first to use quantitative data to measure and compare the use of telemedicine technology between patients and providers. Moving forward, the authors plan to expand the scope of telemedicine at their institution beyond the COVID-19 pandemic measures to fully utilize the vast potential of telemedicine. The findings of this study have also been distributed to the division’s staff to educate providers on the benefits and drawbacks of telemedicine from the patient’s perspective. 

This study has several strengths. The sample sizes of patients and providers is relatively large compared with similar previous studies in this field. The provider group also drew from a variety of different practice types, subspecialties, and geographic regions. The survey questions used were derived from a reliable instrument, the TUQ, and provide strong, detailed insight into the utility of telemedicine from both patient and provider perspectives. 

This study also has certain limitations. The patients surveyed were only drawn from the authors’ institution and may not be representative of the broader population of patients undergoing plastic surgery procedures. The most common income reported by patients was $90,000 USD or higher per year, which is higher than the overall population average in the authors’ region. While this may have had a confounding effect on the survey results, the authors believe the conclusions of the paper are still applicable to lower income patients as well. The patient and provider cohorts also had statistically significant differences in age, gender, race, and ethnicity, which may confound the other findings within the data. 

Surveys are also inherently prone to various forms of response bias, such as extreme responding or courtesy bias, which may have influenced the data. The response rate for the surveys were 13.4% and 5.9% for patients and providers, respectively. Although these response rates are relatively low compared with those of other published surveys, a total of 67 patients and 160 providers participated; consequently, the authors believe the data are representative of the chosen study populations and support the conclusions made in this paper. 

Telemedicine is becoming increasingly ubiquitous throughout many medical specialties, including plastic and reconstructive surgery. The purpose of this study was to survey both patients and providers to gain a better understanding of the utility of telemedicine from both viewpoints. The data collected showed patients rated telemedicine significantly more favorably than providers within the domains of usefulness, ease of use, interaction quality, and reliability. Patients were also generally more comfortable than providers with physical examinations via telemedicine. This study provides valuable new insights into the utility of telemedicine in plastic surgery and the differences between patient and provider perspectives. These findings can help providers optimize their use of telemedicine to provide the best possible care for patients.

Affiliations: ¹Division of Plastic & Reconstructive Surgery, Rush University Medical Center, Chicago, Illinois

Correspondence: Brandon Alba, MD, MPH; brandonejalba@gmail.com

Funding: No funding was received for this study.

Disclosures: The authors disclose no relevant conflict of interest or financial disclosures for this manuscript.

Please answer the following questions: 

1.       Age (free response)

2.       Gender (male, female, transmale, transfemale, nonbinary, prefer not to answer)

3.       Race (American Indian or Alaska Native, Asian, Black of African American, Native Hawaiian, Pacific Islander, White, other, prefer not to answer)

4.       Ethnicity (Hispanic, Latino, or Spanish origin; not Hispanic, Latino, or Spanish origin; prefer not to answer)

5.       Procedure of interest (free response)

6.       Education level (did not finish high school, high school diploma or GED, 2-year college, 4-year college, graduate degree)

7.       Income level (Less than $10,000, $10,000-29,000, $30,000-49,000, $50,000-$69,000, $70,000-89,000, $90,000+)

8.       Distance from your home to your plastic surgeon’s hospital or office, in miles (0-5 miles, 5-20 miles, 20-50 miles, 50+ miles)

9.       Distance from your home to your plastic surgeon’s hospital or office, in minutes (0-5 minutes, 5-20 minutes, 20-60 minutes, 60+ minutes)

10.    Duration of telemedicine visit, in minutes (free response)

Questionnaire: Each item answered on a 1-5 Likert Scale, with 1 corresponding to “Strongly disagree” and 5 corresponding to “Strongly agree.”

“N/A” is also an option for items which are not applicable. 

Please answer the following questions: 

1.     Age (free response)

2.     Gender (male, female, transmale, transfemale, nonbinary, prefer not to answer)

3.     Race (American Indian or Alaska Native, Asian, Black of African American, Native Hawaiian, Pacific Islander, White, other, prefer not to answer)

4.     Ethnicity (Hispanic, Latino, or Spanish origin; not Hispanic, Latino, or Spanish origin; prefer not to answer)

5.     Type of practice (solo practice, solo practice-shared facility, small plastic surgery group practice [2-5 plastic surgeons], large plastic surgery group practice [6 or more plastic surgeons], small multi-specialty group practice [2-5 physicians], medium multi-specialty group practice [6-20 physicians], large multispecialty group practice [6-20 physicians], academic practice, academic practice [salaried with private practice], military, employed physician [hospital, group, or other entity])

6.     Practice in terms of time spent on reconstructive versus cosmetic plastic surgery (100% reconstructive, 25% cosmetic and 75% reconstructive, 50% cosmetic and 50% reconstructive, 75% cosmetic and 25% reconstructive, 100% cosmetic) 

7.     Plastic surgery subspecialty (choose all that apply: general reconstruction, cosmetic, breast, body contouring, craniofacial, hand, gender affirmation, other)

8.     Provider credentials (MD/DO, PA, NP, RN, other)

9.     Primary practice location by state 

10.  Distance from your home to your place of practice, in miles (0-5 miles, 5-20 miles, 20-50 miles, 50+ miles)

11.  Distance from your home to your place of practice, in minutes (0-5 miles, 5-20 miles, 20-50 miles, 50+ miles)

12.  Average duration of telemedicine visit, in minutes (free response)

13.  Do you bill for telemedicine visits (Yes, at the same rate as an in-person visit; Yes, but at a different rate than an in-person visit; No, we do not bill for telemedicine visits; Our billing practices for telemedicine have not yet been established)

14.  What telemedicine system are you using the most for telemedicine visits (Doximity, Zoom, FaceTime, Vidyo, Updox, Modmed, OnCall, Klara, Epic, other)

Questionnaire: Each item answered on a 1-5 Likert Scale, with 1 corresponding to “Strongly disagree” and 5 corresponding to “Strongly agree.”

“N/A” is an option for items which are not applicable.