Why "sub-specialisation" matters.
May 17, 2022
January 28, 2022
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By Dr. Andrew Campbell-Lloyd

Why "sub-specialisation" matters.

Let me ask you this:

If you are considering an operation, do you want surgery performed by a surgeon who does that specific operation everyday? Who is obsessed with the details of that procedure and all the tiny things that can make it better? Who has the numbers to allow them to see how small changes can translate into large differences in outcomes? Do you want that surgeon?

Or do you want the surgeon who will have a go at that operation every now and then, and who is just relieved that it didn’t all fall to pieces?

I can't imagine that the answer would be anything other than the obvious. But what if you couldn't tell whether a surgeon was the former, or the latter? Then it gets tricky.

 

By definition, all plastic surgeons, indeed all fully-trained surgeons or physicians, no matter the field, are “specialists”. The term “specialist” is used by the public to refer to doctors who have completed training beyond that required for general registration, to become capable at managing a certain part of the ever-expanding realm of medicine. People see “specialists” if they need knee surgery, bowel surgery, eye surgery,or breast surgery. They see “specialists” if they have kidney problems, lung problems or high blood pressure.

So, the term “specialist” has perhaps lost a little meaning along the way.

One of the things that occupies my thoughts is the problem that arises when surgeons “have a go” at anything, just because they can. This is particularly something we see in Plastic Surgery. How many plastic surgeons have websites on which they proclaim to be “leading surgeons” who are “highly skilled” or “experts” in pretty much EVERYTHING. They might claim to have “special interests”, but they list their interests as everything from facelifts, to rhinoplasty, eyelid surgery, breast surgery, body contouring, hand surgery, skin cancer surgery,  craniofacial surgery, surgery for women, surgery for men, laser surgery, cosmetic injectables….and the list goes on. But can anyone really be an expert in everything?

“Jack of all trades, master of none”, right?

Times have changed. Thirty or forty years ago when much of modern surgery was still nascent, it would have been fair to say that a surgeon could reasonably have a go at most things. There were far fewer surgeons, the breadth of the specialty had not expanded to its current state, and certainly, patient expectations were nothing like what they are today.

Plastic Surgery is 2022 is a vast field. It continues to grow rapidly.

It is totally disingenuous for any surgeon to claim to have expertise across the entire specialty.

It is clear that the term “specialist” means far less than it once did. Most “specialists” are in fact “generalists” within their given field. And this has in turn given rise to the requirement for “sub-specialisation”.

For me, my sub-specialty expertise lies in the field of breast surgery. In particular, breast reconstruction and revision breast surgery. But how do I justify making this claim? That is a fair question that anyone is entitled to ask me.

Like any surgeon claiming a sub-specialty, I have a number of "fellowships" behind me. These fellowships entail further training after the completion of specialty training, - often overseas - typically working in high volume centres that may be recognised for excellence in a particular area. In my case, after I completed my plastic surgery training in Australia, I chose to educate myself for a further 18 months exclusively in the fields of reconstructive and aesthetic breast surgery.  I moved to London and worked at St Thomas' Hospital, which is a very high volume breast reconstruction centre. Having said that, my training alone did not set me up to do what I do. I am a product as much of experience as I am of training.

My training allowed me to "claim" a certain expertise. But it is only by focusing on breast surgery in my subsequent practice, to the exlusion of other parts of plastic surgery, that I have over time increased my exposure to the types of things that other surgeons may see less frequently. That exposure has lead to greater expertise.

By narrowing my focus, I am confident that I can deliver outcomes as good as, if not better, than anyone else. I think I have continued to improve over time. Because I do the same operations day after day, I have been able to tweak and refine my approaches, based on close observation of my outcomes; something that wouldn’t be possible if I was only doing these operations occasionally.

If we accept all of that, then it is logical to accept that the gap between a sub-specialist, especially in what we might consider “niche” areas like explant surgery or revision breast implant surgery, and another surgeon who may be perfectly capable of something like a breast augmentation, but who only does a revision case a few times a year, will actually continue to widen. Which only reinforces the argument for sub-specialisation.

And here is the corollary of my position: I do not offer facelifts, or rhinoplasty, or even blepharoplasty, for one very simple reason - because whilst I technically can perform these procedures, I believe that there are other surgeons out there with greater experience in those operations and who will achieve better outcomes.

Anyway, it all then comes down to a sense of personal morals I guess. If I claim to do procedures that I might only have a crack at every now and then, then my outcomes will never be as good as those of my colleague who does that same procedure several times a week. Which would mean I am choosing to put money before my patient’s well-being.

I believe that whether in capital cities or in regional centres, patients deserve access to sub-specialists. I stand strongly by this opinion. There are more than enough surgeons in this country to ensure equitable access to high quality care, including sub-specialist care.

One thing I am certainly seeing more of is a willingness of patients to travel to find a surgeon who does speciaIise in a particular procedure. This is as much a by-product of the ability for patients to research a given surgeon online, as it is a consequence of their desire for the best outcome from a given procedure.

Patients no longer rely on their GP's to refer them to the "best" surgeon for the job - now, particularly in sub-specialty fields, the patient finds the surgeon and then tells the GP who to refer them to.

The need for sub-specialisation will only deepen in the coming years. Patients are demanding it, and surgeons better get used to it.