Plastic surgery has come a long way during my career. Understanding of anatomy and the blood supply of tissues has allowed us to revolutionise reconstruction following trauma and disease. That same knowledge has also enhanced aesthetic techniques, producing results that are more natural and longer lasting. Science has been introduced to allow better understanding of the healing process, of how tissues behave and age, and has allowed the creation of safe implantable materials to enhance results. This knowledge base continues to grow but, today, we can achieve outcomes that our forefathers could only dream of.

At the same time, how medical care is delivered is also changing. We now live in a litigious society, where blame has to be apportioned to someone; ‘bad luck’ is no longer recognised as an explanation. As a result, clinicians are becoming more cautious, no longer trying to push the boundaries, instead finding themselves forced into safe middle ground and mediocrity.

Naturally imperfect
Surgery is not an exact science. Results are influenced by the problems of wound healing and the limitations of genetics. Complications do occur, no matter how good the surgeon and how well the procedure is executed. Anatomy is variable and that variability usually only presents itself at the time of surgery. Everyone runs the risk of infection, which is rarely down to poor technique. Haematomas (collections of blood) do occur, and the quality of scarring is unpredictable. Nature provides a dynamic palette, which we endeavour to harness.

The legal system and the regulation of medicine, however, are increasingly slanted towards the patient in the role of victim. It now costs nothing to sue a doctor, while the latter’s costs in successfully defending themselves are no longer recoverable. Clinicians are guilty and have to prove their innocence. We are expected to educate patients into understanding all the options available and not just the best one for them. We have to show that they have made informed decisions. The paperwork can now take longer than the procedure, so that every detail of care can be justified.

False economy
The internet and media have increased patient expectations. Information is shared instantly, but proficiency has to be established. The limitations and complications of treatments are highlighted as errors. Lawyers advertise on TV screens in hospitals, and patients are encouraged to complain. As a result, delivery of medical care is being pushed towards protecting the system rather than benefitting the patient. More and more it is consultant-performed, rather than consultant-led.

This may seem good, but it has implications for the future. Surgical throughput is being reduced and costs are going up. New layers of managerial staff are required to cope with the burden of increasing regulation. The emphasis is on defensive medicine, where clinicians are discouraged from thinking outside the box. Consultants are becoming blue collar workers, working within set rules even though nature has none. More worryingly, if all surgery is carried out by senior people, how is the next generation trained? We all have to do our 10,000 hours to become proficient, and this comes from learning and adapting techniques to suit us.

Somewhere, the system has to accept that all doctors endeavour to do their very best for patients and that all procedures have limitations. Perfection has to be tempered with realism if we are to continue advancing medicine into the future.