To reach out to patients, more plastic surgeons are sending out e-newsletters instead of traditional printed newsletters. E-newsletters bring the interactivity of the Internet to a time-honored patient-loyalty tool.

But the Internet’s connectivity comes with a price—namely, chaos! Spammers have infested in-boxes with exasperating messages that are like ants in the kitchen.

They are impossible to stamp out, and they force us to throw out good mail along with the bad. Getting legitimate e-mail into subscribers’ in-boxes—what professional e-marketers call “deliverability”—is now the number one problem facing the industry.

The Spam Factor

An estimated 10 out of 12 messages being delivered to the average in-box are considered spam,1 and the average user now receives 42 unwanted pitches per day.2 To protect the public from this influx, Internet service providers (ISPs) such as Yahoo!, Hotmail, and Earthlink have installed a vast system of spam and bulk-mail filters. But these filters also heedlessly deflect e-mail that the public wants and expects to receive.

Do you have a list of subscribers who want to get your e-newsletters? Don’t assume they can.

E-mail sent out in bulk (rather than from one individual to another) is now guilty until proven innocent in the view of these ISPs. By 2008, the cost to legitimate businesses of incorrectly blocked opt-in e-mail will rise to $419 million.2

The number of in-boxes that receive your bulk e-mail is known as the “open rate,” which currently averages around 30% of a total database. This is today’s “respectable” rate for legitimate professionals. But this is far from satisfactory.

You worked hard to develop a list of loyal patients and Internet leads. These patients asked to receive your e-newsletter, yet two thirds of them could miss seeing it every month, mostly because of spam filters.

On top of this, the more you send mail to a database, the lower the open rate gets. Dwindling open rates are par for the course in e-marketing.

While spammers are responsible for 90% of low delivery rates for e-marketing, other factors enter into the equation, too. A few of these, including the quality of your database and the relevancy of your message, are under your control.

So, while the general picture shows an Internet in chaos, the smaller picture is more hopeful for your legitimate e-newsletter. Smart, aware e-marketers can implement these seven best practices to improve open rates.

Best Practices

1) Protect your reputation. The major factor in all blocked e-mail is the reputation of the sender. Of course, “reputation” here does not mean your record as a physician—the ISPs are looking at the reputation of the server your e-mail is sent from.

The ISPs track where spam is coming from and put up roadblocks against senders with bad reputations. Server reputation accounts for about 83% of unfairly blocked mail.

Generally, multiple users contribute to the server’s reputation, which means there is the risk of guilt by association. If a bulk e-mail distributor has a spammer among its clients, and your e-mail is sent from the same server as that spammer’s mail, you can be blacklisted.

Clearly, server reputation can make or break your e-newsletter, so it is important to research the reputation of your e-mail distributor. Find out what the distributor does to keep spammers out of its systems, and ask how it educates its legitimate e-marketers to avoid spam-like behavior.

There are dozens of strategies that reputable distributors can use to keep their clients on the high road. Make sure your distributor is using all of them.

If your practice-management software has an e-mail module, and you are using it to send bulk mailings, you must monitor your reputation on your own. When you move your bulk e-mail through a server, you’re joining a crowd you don’t know.

Thousands of other businesses and individuals are using the server. If you’re lucky, none of them is sending out malicious e-mail.

If not, you are in danger of being blacklisted at one or all of the ISPs. If you are blacklisted, all of your patients who use that ISP are blocked from getting your e-newsletter.

If you do get blacklisted, you’ll need professional help. Companies like Return Path ( help e-marketers solve their deliverability problems. They assign scores (like credit bureau scores) to servers sending out bulk e-mail.

See also “A Movable Feast” by Catherine Maley, MBA, in the June 2007 issue of PSP.

If they find out your reputation has been tarnished, they’ll help you negotiate with ISPs to allow your e-mail to be delivered, remove your address from blacklists, place you on whitelists, and generally advocate for you with the powers-that-be in cyberspace.

While these services are available, they should be employed only as a last resort, because rebuilding your reputation involves an arduous process with difficult reports for you to wade through. The best strategy is to avoid being blacklisted in the first place.

2) Ask for permission. The January 2004 Federal CAN-SPAM law introduced a number of rules regarding the delivery of e-mail. The most basic: e-marketing must be permission-based.

Unlike advertisements, which can be broadcast to one and all, or postal direct mail that can be sent to purchased lists, e-mail marketing messages must be based on prior permission. People have to express a desire to receive your e-newsletter. Otherwise, you can’t send it to them.

For physicians, this pinpoints just three viable sources for your e-newsletter database:

  • Your intake forms. The line on your intake form that asks for your patient’s e-mail address must clearly request permission to send them an e-newsletter. Don’t assume permission and offer a checkbox to decline it. That is not the same as asking permission.
  • Your Web site sign-up box. You can place a dedicated sign-up box on your Web site inviting visitors to receive your newsletter. This is a viable source for your e-newsletter database. You may not use e-mail addresses from other sign-up boxes, such as the one where you offer to answer procedure questions.
  • Sign-in sheets at community events. If you have clearly offered your e-newsletter on a sign-in sheet at your lecture or seminar and received e-mail addresses in response to that offer, you may add those addresses to your e-newsletter database.

Do not add e-mail addresses from directories and portals (Locate-A-Doc,, etc). You have not requested permission to send bulk e-mail to the addresses given to you by these directories.

The addresses they send you have been harvested electronically, without the owners’ knowledge. While you may send individual e-mails to harvested addresses (there’s no law against it), you cannot legally send bulk mail to these addresses.

Other illegitimate addresses are those from purchased lists or ones that have been “scraped” from the Internet. Again, the address owners have not given permission.

Adding illegitimate addresses to your database hurts you. People angered at getting unsolicited mail will send in spam reports. As a result, your distributor may lock your account, and you can be blacklisted from individual ISPs.

3) Maintain a clean list. Always promptly remove undeliverable and nonexistent addresses from your database. ISPs keep track of the mail trying to reach their clients.

If you try again and again to deliver messages to closed mailboxes, you are seen as a pest—or worse, a spammer. This will get you blacklisted.

4) Send relevant information. Think about the e-newsletters you’ve subscribed to. Which ones do you look forward to reading? Which do you delete when you’re busy? Which have you opted out of after a few issues?

Chances are you look for information that helps improve your performance, keeps you informed about important legal decisions affecting your practice, gives you an edge over your competition, or answers another need for your practice. Anything that doesn’t help you is a time-waster.

To provide this type of relevance to your own audience, your e-newsletter should address one question only: What can you tell your patients right now that will help them look better?

Bargain-priced e-newsletter services have cropped up recently. Targeted to cosmetic surgeons, these services offer what appears to be a terrific deal: a monthly choice of prepackaged articles within an automated system that includes digital lead tracking.

There’s only one problem: The content isn’t relevant. It’s slick and pretty, but generic. Most patients will immediately get it: You’re sending them warmed-over content.

It’s not specific to your practice. It has nothing to do with their needs. It’s not from you to them. They’ll opt out immediately.

It is better to send a simple, text-based e-mail with a personal message and information that only a plastic surgeon—not a consumer magazine—would know. Slick, generic e-mail is the junk mail of the digital age.

5) Don’t send ugly stuff. Once you’ve committed to including only relevant content, make sure it’s presented well. The content should be organized and clear.

Ugly, cramped e-newsletters with overlapping text and amateurish design reflect badly on you. You are, after all, positioning yourself as an expert on aesthetics.

By the same token, don’t go overboard with graphics. A ratio is 20% pictures to 80% text.

6) Avoid red-flag content. Learn what to avoid to ensure your e-newsletter doesn’t get trapped by a spam filter. ISPs filter based on a number of factors:

  • Words and phrases. Choose your language carefully when crafting messages. Avoid hot-button topics often found in spam, including medication, mortgages, money-making strategies, and pornography.
  • Attachments. Don’t use attachments, because those from unfamiliar sources are unwelcome. Phishers—more dreaded even than spammers—do their nefarious work through attachments.
  • Subject lines. Keep your subject line simple and direct; for example, “News from Montrose Plastic Surgery” or “News from Dr Donald Montrose.”
    If you have some important news that might grab your reader’s attention, it is OK to write, “We’ve Moved to a Beautiful New Facility” or “Our New Laser Has Arrived.” But it must sound sober.
    Don’t use superlatives or exclamation points (“Our Fabulous New Laser Is Here!”). Avoid huckster language that may be mistaken for spam.
  • From lines: Use only your name or the name of your practice. Your subscribers should instantly see they are getting legitimate e-mail from a legitimate source.

7) Provide a reliable opt-out link. Some people change their minds and realize they don’t need a newsletter about aesthetic medicine. Let them opt out. They won’t be coming in to your practice anyway, so release them and be grateful for your remaining readers.

Place the opt-out link at the top of your e-newsletter. Don’t make people search for it. If they have to work too hard to find it, they’ll do what’s easiest—send in a spam report.

A Worthwhile Effort

While you will never know exactly how many people open and read your e-newsletter (cyber-reporting is far from infallible), if you follow the above practices, you will get enough readers to make your e-newsletter worth the time and money you spend on it.

Remember that in the old days, when printed newsletters were delivered by postal workers, physicians never knew how many people actually read their newsletters. Most newsletters were probably tossed out with the grocery store coupons. But the ones that grabbed people’s attention apparently made the $3,000 to $5,000 investment per issue worthwhile.

E-newsletters are vastly more cost-effective than printed newsletters. Done right, they’re great loyalty and prospecting tools. The chaos of the Internet shouldn’t deter you from trying them—but do make sure they get delivered.

Joyce Sunila is the president of Practice Helpers, which produces and distributes patient e-newsletters for aesthetic physicians. With a background in medical writing and editing, she’s been marketing hospitals and private practices for 30 years. She can be reached at (866) 706-0550 or via her Web site,


  1. Accessed September 19, 2007.
  2. Accessed September 19, 2007.