I am delighted to have been voted as Plastic Surgeon of the Year for a third time. I work in a speciality where we all try and achieve excellence and it is rewarding when those efforts are recognized.

Plastic surgery has come a long way during my career time. Understanding of anatomy and the blood supply of tissues has allowed us to revolutionise reconstruction following trauma and disease. That same knowledge has 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 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.

Delivery of medical care though, is changing. We live now in a litigious society, where blame has to be apportioned to someone; bad luck no longer happens. As a result, clinicians are becoming more defensive; no longer trying to push the boundaries, but being forced into the safe middle ground and mediocrity.

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 presents itself, only, 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, is increasingly slanted towards the patient, as the victim. It now costs nothing to sue a doctor, but their 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.

The internet and media have increased patient expectations. Information is shared instantly, but proficiency has to be established. Limitations and complications of treatments are highlighted as things that have gone wrong. Lawyers advertise on TV screens in hospital waiting areas. Patients are encouraged to complain. Even a Health Minister publically criticised a group of surgeons, stating, “Do you realise that half of these surgeons are below average”; something that can never change, no matter how good they are. 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 major implications into the future. The surgical throughput is reduced and costs go up. New layers of managerial staff are required to cope with the burden of ever increasing regulation. The emphasis is on defensive medicine, where clinicians are discouraged from thinking outside the box. Consultants are becoming “blue collar” workers; working to set rules, when nature has none. More worryingly, if all surgery is carried out by senior people, how is the next generation trained? A career in surgery is an apprenticeship. We all have to do “10,000 hours” to be proficient. Proficiency comes from learning and adapting techniques to suit us, as individuals.

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.