When he opened The New York Times Magazine earlier this year to a full-page ad in which surgeons at the University of Illinois Hospital & Health Sciences System in Chicago extolled the benefits of their da Vinci robotic surgery program, Paul Levy recoiled in distaste.

Levy, the ex-CEO of Boston's Beth Israel Deaconess Medical Center and now the publisher of an influential blog called Not Running a Hospital, questioned the ethics of a public, nonprofit medical center lending its name and reputation to the promotion of a very expensive commercial product whose effectiveness is still in dispute.

What's more, he discovered, some of the members of the "surgical team" pictured in the ad were listed in small print as receiving compensation from the makers of the da Vinci system — Intuitive Surgical Inc. — which had paid for the ad and whose copyright was appended. Not all those posed in white coats with the group were even clinicians.

Under the headline "Time to fire somebody," Levy described in his blog his indignation at whoever was responsible for approving UI Health's participation in the ad. It violated the university's own policy forbidding commercial endorsements, he pointed out.

As the story gained legs nationally, the university announced that it had asked Intuitive to suspend the campaign "based on a business decision … that the ad was not benefiting UI Health." Officials said they would conduct "a methodical assessment of policies, guidelines, procedures and practices." (They have done so. Mistakes, they concede, were made. Future oversight will be tightened. Nobody is known to have been fired.)

U.S. hospitals spend more than $1.5 billion annually on advertising — better than $2 million a year from the marketing budget of the average 400-bed facility. Hospitals often tout their early adoption of emerging technologies from private device companies — robotic surgery systems like Intuitive's da Vinci, Accuray's CyberKnife, 3-D mammography like Hologic's Selenia Dimensions. Sometimes the maker is named, sometimes a generic term for the technology is used, but the company logo on the equipment is prominently visible. Sometimes the manufacturer pays for the ads rather than the hospital. Many clinicians offer testimonials on company websites — their affiliations explicit, not so whether there was a quid pro quo.

An Infraction of Good Taste

My father was a lawyer. He hated trial work, but he was very good at it. He once represented a brakeman who, although frantically waving his lamp, was run down by his own train when a switch pinned his foot. The man was young, with a wife and children. He lost both legs. The railroad's lawyer, the opposing counsel, was Potter Stewart, later a justice of the U.S. Supreme Court.

My father won that case. And the verdict made headlines because it included by far the largest personal injury award recorded in Ohio until then. Years later, on a trip to Washington, D.C., my father encountered Justice Stewart, who turned to his companions and volunteered, "Do you know George Weber? He gave the most moving closing argument I've ever heard in a courtroom."

What an endorsement that would have made, emblazoned on an advertisement for my father's law practice! But he wouldn't have dreamed of advertising — he disdained it as unethical. So did all the respectable lawyers, doctors and hospital administrators of his day. Theirs were the "learned professions" — closed societies whose lofty values transcended petty competition (theoretically).

It may be surprising to reflect that not until 1977 did the American Hospital Association countenance advertising by its members. But the organization counseled against "[s]elf-aggrandizement of one hospital at the expense of another," warned that "[q]uality comparisons, either direct or by implication … may be counterproductive" and tut-tutted that "[c]laims of being 'the best' or the 'most efficient' are always open to criticism and should be avoided."
In a 2004 essay in the Journal of the Economic Business & History Society, Lauren Strach of Andrews University notes that the American Medical Association still upheld even stricter standards. "Solicitation of patients, directly or indirectly, by a physician, by groups of physicians, or by institutions or organizations is unethical," she quotes the contemporary AMA Code of Ethics. … "Self-laudations defy the traditions and lower the moral standard of the medical profession; they are an infraction of good taste … ."

Encouraging the Flow of Information

Two years earlier, however, the Federal Trade Commission had lobbed the grenade that would explode that cozy world of learned professionalism — rife with price fixing, secrecy about processes and outcomes, restraints on innovation … all features, not bugs, of the status quo. The agency ruled that the AMA and local medical societies could not forbid practices like advertising and price adjustment: Health care, too, was a competitive marketplace. Its practitioners and organizations were subject, just like the minions of "trade and commerce," to antitrust laws designed to promote the public interest.

The AMA challenged that ruling, but it was upheld by the Supreme Court in 1982. (Stewart, incidentally, had retired the year before, to be replaced by Sandra Day O'Connor.) Under the new dispensation, the AHA revised its guidelines. "[A]dvertising to help maintain or attempt to increase market share for specific services and programs" is acceptable, the AHA allowed in 1990; it "can result in the efficient, appropriate and cost-effective use of services to benefit both the consumer and the health care facility."

Legitimate purposes for advertising, as outlined by the AHA, include educating the public about available services, promoting good health practices, accounting publicly for the hospital's use of resources, winning support for fundraising campaigns (but not communicating a political point of view) and recruiting employees.

"[H]ealth care facilities should approach their advertising investments with the same spirit of fiduciary responsibility that is applied to the purchase of other health care commodities, such as new equipment or buildings," the AHA declared.

We Would All Be Better Off

You don't have to look far to find critics who'd like to see a return to the good old days.
"The decline of medicine as a profession began when it became legal for doctors and hospitals to advertise," grumped "Skeptical Scalpel, M.D.," in a recent post on his widely read doctor-blog of the same name.

"Just like car dealers," the retired surgeon complained, "every hospital in my area is 'No. 1' in something or other. Often more than one hospital is No. 1 in the same specialty … . In addition to wasting a lot of money, hospital and physician advertising is harmful because it creates unrealistic expectations among patients … . If … [advertising] disappeared tomorrow, we would all be better off."

Although hardly willing to go that far, Chris Bevolo, a veteran health care marketing consultant based in Minneapolis, agrees that hospitals are mostly misguided when they indulge in a "selfie" like UI Health's mass-media boast of its da Vinci prowess. ("Free publicity for our program," the surgeons had exulted.)

First, he asks, how many people who saw the ad actually needed robotic surgery? The same criticism holds for most of the clinical services hospitals often center their ad campaigns on. How many New York readers — or Californians or Floridians — are going to travel to Chicago for a robotic hysterectomy? Especially when it can be done at home with cheaper and, according to some studies, more reliable, traditional laparoscopic techniques.

Of course, acknowledges Bevolo, one rationale for that kind of ad is to build the hospital's brand — create a general impression that it's a place where sophisticated clinicians work with state-of-the-art equipment. But, in fact, hospitals all over the country now offer robotic surgery. Notwithstanding his doubts about its clinical necessity, even Levy reluctantly acquired a da Vinci robot for Beth Israel Deaconess when he was running the place; patient queries (driven by just such ads as UI Health's) made it a competitive necessity.

"Spending a million dollars to promote the message of 'We care,' or letting folks know that your team of arm-crossing orthopods 'has your back' is still a waste of money," scoffs Bevolo. "From a marketing perspective, imagine what you could do with the million dollars that was wasted on flashy, chest-pounding ads. Create an unreal interactive experience? Offer community education on diabetes, weight loss or stress-reduction? [Buy] cloth robes for breast cancer patients? … [Create] compelling, relevant health and wellness content? Offer a dozen online health risk assessments? The list goes on and on."

At least half of all mass advertising by hospitals is spurred by "political pressure internally rather than established marketing strategy," he suggests. Specialists see a billboard promoting their counterparts at the hospital across town and wheedle, "Why aren't we on a billboard?" Those in the C-suite sigh and indulge them to forestall one more battle.

"In fact," declares Bevolo, "the business case for hospital advertising — especially mass advertising — is extraordinarily poor. It's notoriously difficult to measure the impact of the ubiquitous 'brand campaigns' that are all about awareness and perception-building and have no freaking call to action. But the effectiveness of mass advertising from a cost-benefit perspective pales in comparison to more targeted efforts, such as search advertising, direct mail, community seminars and more. Yes, some of that is advertising, but it's the mass advertising that's getting us in trouble."

Which is certainly what UI Health bought for its misstep on the national stage. Caveat advertisor: Don't let robots market your hospital.

David Ollier Weber is a principal of The Kila Springs Group in Placerville, Calif., and a regular contributor to H&HN Daily.