Opinion An open letter to young plastic surgeons (from an old UK plastic surgeon) Y ou are in a specialty that is second to none – you can use your skills to improve the quality of life of your patients, whether they have cancer, congenital abnormalities or damage caused by trauma. Most (90%) plastic surgery patients fall into the above groups, but 10% ask for so- called ‘cosmetic’ surgery. The problem is that, in the private surgery sector in the UK, the 10% cosmetic surgery patients make up 90% of private plastic surgery. The NHS now carries out hardly any cosmetic surgery, because people sitting in meetings have decided that they can save costs by eliminating this group. So, your training is in the NHS, but 10% of plastic surgery (and 90% of private patients) is out of your reach, so how can you learn about it and become expert at it? Let’s take an example – rhinoplasty. When I was an senior house officer (SHO) I watched, say, 10 and made notes on my little Kardex cards, then I assisted for 10. These were closed rhinoplasties so everything was upside down and inside out and hard to visualise. Next, I did 10 with firstly a registrar helping; and then the senior registrar assessed me a few times before I was allowed to go solo. The anaesthetist and theatre staff were very tolerant because the operation could take hours! When the boss was going on holiday we would get in a few rhinoplasty patients from the (five year) waiting list, so we could practise our new found skills! A different world I think. My initial training in rhinoplasty involved surgery on at least 50 patients; and even then the operation was stressful. With little or no practice in the NHS, the young surgeon must now rely on the spoken word at clinical meetings. The sad reality is the non-clinicians are now in charge of part of our training and the value of cosmetic surgery has been devalued. So how can you train in cosmetic surgery and work in this section of your specialty; that you are particularly well qualified to do? You have the skills of tissue handling and dexterity of dissection and suturing that members of other specialties have yet to, and may never, attain. The first decision you must make is – do you want to do cosmetic surgery? The stress levels can be high, the insurance rates are high and rising alarmingly, it takes years to become established and the other surgeons are envious because they assume you are earning millions. The converse is, most of the patients are lovely and very grateful, the rewards can be high and you will pay lots of tax; and the surgery is both a challenge and very satisfying. The odd patient is a nightmare and can give you sleepless nights, but most will tell you that you have improved the quality of their lives – which is what it is all about. So if you opt out of cosmetic surgery you will have a wonderful time in the NHS, in the best specialty of all. If you decide to stick with cosmetic surgery there are some important things to decide and tough decisions to make. Don’t do cosmetic surgery because you are not sure about your prospects in the NHS, there are plenty of other things you can do. You must have commitment. Many surgeons have come to watch me but spend time chatting on their phones. The surgeons who watch, make notes and ask questions are the ones that I enjoy being with. It sounds like stating the obvious but it is amazing how some show little real interest. The next important thing is you must see a lot – then do a lot – first with a guiding supporter and then as prime operator. Seeing a lot is really important because a good surgeon is the sum of the best bits of all the other surgeons he has watched. In other words get out there and ‘compare and contrast’. As an SHO I managed to get a British Association of Plastic Surgeons (BAPS) ‘travelling fellowship’ and my boss arranged for me to see some of his old friends in Germany, Belgium and France. I am still using some of the techniques I learnt there 35 years ago! The biggest problem is ‘doing a lot’. The Private hospital managers soon realised that a surgeon working in some parts of Europe earns a tiny fraction of the average private practice earnings in the UK. So in in comes the EU working regulations, along with qualified European surgeons and up goes the private hospital profits. The surgical differences across Europe are very large. In Italy and Germany for instance the training is deficient in actual practical experience because the boss does everything. In Eastern European countries the average monthly salary in the public health service can be less than the surgeon’s fees for a single operation here. I have actually briefly worked in Serbia and Romania, and while the plastic surgeons were of very high quality and a credit to the speciality, they were working with ancient equipment and poor resources. So what of the future? As things stand, training in the NHS is going to be deficient now, so the only place to gain the necessary experience is in the private sector. A dialogue between the plastic surgery hierarchy and the private hospital owners should take place; and be meaningful and ongoing, with an ambition for frank cooperation. Hospital managers (including the NHS) want to economise and increase their profits, they have the time and training to make decisions about working methods, but we should be involved in the decision making rather than just meekly accepting their announcements. Young (and old) plastic surgeons should be able to plan their working ambitions in an open manner, entering ‘clinics’ through the front door. There are actually a lot of consultant plastic surgeons who have worked in the commercial sector, they know how things operate and should be advising a panel of cosmetic surgeons and planning the future of this important branch of our specialty. A new opportunity has arrived with the new proposed regulation of cosmetic surgery, so the protectionism of the past should be forgotten forever and the safety and wellbeing of our patients put first. pmfa news PAUL LEVICK , COSMETIC SURGERY, PLASTIC AND RECONSTRUCTIVE SURGERY, THE PRIORY HOSPITAL, EDGBASTON, BIRMINGHAM. Get in touch Do you agree with Paul or has your experience been different? Email diana@ pinpoint-scotland.com to share your thoughts on training in cosmetic surgery, or use the hashtag #anopenletter on Twitter. Correspondence: Paul Levick on info@paullevick.co.uk volume 3 issue 1 I 11