Once upon a time, search engines let you freely add your Web site to their directory and it would appear reasonably high in the search results. Today, that's just not so. Previously, search result algorithms primarily used a site's keywords and content to rank it. Current algorithms use a complex calculation consisting of page popularity, keyword density and other factors. If it wasn't confusing enough, a group of people calling themselves search engine optimizers have sprung up, offering fee-based search engine optimization (SEO) services that allegedly raise improve a site's ranking. So to whom does a technopeasant turn when it comes to having your site be listed on search engines and is it worth it? If not, what other alternatives exist?

For more than 99% of you, I do not believe that paying for SEO is worth it. You're in a competitive industry with intense pressure on reimbursement and you rely on local residents to support your practice. If you're in Houston, its unlikely that someone from Minneapolis will become your patient. So paying for a high ranking on a generic phrase like “back pain” will not likely generate enough return on investment to be worth it. Finally, there are many hucksters, or simply incompetent people, out there who employ black-hat tactics that may work in the short-term, but may have your site banned in the long term. If you're determined to pay for this service and want to be educated, visit SEO Pros (www.seopros.org), the industry's accrediting organization.

The one search engine registration task you should do is to list your site with the Open Directory Project at www.dmoz.org. It will take time for your listing it to appear, but this free directory is used as a source by many others and the listing process is simple.

Most search engines place a couple of sponsored links on top of the results and more down the right side. This type of advertising is called paid-inclusion and it is my favorite way of attracting site visitors.

Here's how this works. There are two major ad networks: Google and Yahoo (formerly Overture). You select a word or phrase that relates to the service you offer or condition you treat, create a short ad and decide what you're willing to pay for placement on the search results page when someone searches on the word(s). For all practical purposes, the primary difference between the two networks is the bidding mechanism: Yahoo lets you see your competitors' ads and bids; Google does not. Both only charge you when your ad is clicked.

Both also allow you to implement a localization feature so that people who are connecting to the Internet from Cleveland will see ads for Cleveland businesses. Many advertisers will create a local campaign and a national campaign. An example of a local campaign might be the words “back pain” whereas the national campaign might use the words “back pain Cleveland.” If a Clevelander searches on “back pain,” they will be shown the first ad, whereas the New Yorker will be shown the Cleveland ad if they search on “back pain Cleveland.” Obviously, people who perform a local search are much more likely to use a local service provider.

Pricing is also different at the local level. For example, “back pain” costs about $1.53 per click to be listed first on Yahoo, but “back pain Miami” costs 41 cents. Some markets are more competitive, however. “Back pain Los Angeles” costs $6 to be listed first, but just 12 cents to be listed second. Obviously, there is some budgeting strategy to consider when creating campaigns and it may not be worth it to pay to be first.

Without question, your ads should take visitors to targeted sections of your Web site. If you advertise on “sciatica,” the visitor should be taken to a page about sciatica as opposed to the homepage. Also, you should have an action that visitors take that provides you value, such as an Evaluate My Condition form. Having visitors is nice, but has less value compared to having the contact information of people interested in your services.

For example, Visitor A clicks your “sciatica” ad and Yahoo charges you 51 cents. The visitor reads the material and leaves the site. You know you had a visitor, but the value is minimal and you don't know why they didn't go onward. Visitor B goes further and views the Evaluate My Condition form and leaves the site. The value is conceptually higher. Did Visitor B find the form is too complex, or were they not that interested? You don't know for sure, but if 1-in-1000 submit the form, the problem is likely with the form and not the level of interest. Visitor C actually completes the form, producing the highest value because now you can contact them.

Shifting gears for a moment, your Web host should provide a tracking tool that lets you see how visitors found your site, what pages they viewed, the most common paths through the site and many other stats. If not, or if the tool isn't user-friendly, there are two that I recommend. One is called ClickTracks (www.clicktracks.com) and the other is called Visitorville (www.visitorville.com). Both provide you with fantastic information and Visitorville literally shows a virtual city with traffic represented by moving pedestrians, cars and buses pulling up to buildings, etc. Either tool is useful when it comes to tracking site activity.

You use the tracking tool so that you can see patterns. For example, I recently completed a 16-month study for a company and we have identified an equation for measuring the return on investment in paid-inclusion ads. In any given month, 5% of the visitors view the Contact form. Of those, 18% submit it and 25% of them become customers. Each customer purchase is worth about $15,000. So, 1000 people visit. 50 view the form. 9 submit it. 2 become customers = $30k. The company spends $1,600 a month on Google and Yahoo combined and another $750 - $900 a month to manage the campaigns, so call it $2,400, to earn $30k. That's a solid return in an industry with 4 million Web sites competing for placement.

Unlike other advertising campaigns, paid-inclusion ads produce a measurable result almost instantly. Patterns take time to develop, as does learning which search terms and advertising language are more likely to produce a valuable click. For example, a friend owns a rental property in Costa Rica. Would you have guessed that the highest performing term is the misspelling, “Costa Rico?” On Yahoo it costs 56 cents instead of $1.64 for Costa Rica, so his $60 monthly budget is better spent on the misspelled word.

Search engines are still the primary method for driving Web site traffic. SEO is, to me, a murky, ever-changing arena with a very high cost to establish and maintain a presence. By contrast, paid-inclusion ads cost far less to establish and the maintenance cost is tied to what you are willing pay for clicks. For me, I pick pay-for-performance every day of the week and advise you to do the same.