Invited EURAPS JPRAS Editorial Conflict of Interest in Plastic Surgery

Plastic Surgery has always been a small specialty, based on a philosophy of innovation, which opened up undreamt of surgical avenues in which we lead the world. However, it also means that we often have difficulty in the international surgical political hierarchy. Plastic Surgeons can also feel under threat in the cosmetic surgical sphere and exposed to the media unlike any other surgical specialty. The profile of the specialty can be an active source of conflict, including conflicts of interest.

Plastic Surgery's small size internationally brings with it both benefits and challenges. One major benefit is the excellent international working relations between national and international associations, as well as between individual Plastic Surgeons. However, our small size also means that conflict of interest, which lies at the heart of many difficulties at every level in surgery, can cause havoc in how the specialty perceives itself, as well in how others perceive both it and us, as Plastic Surgeons.

The Covid crisis has probably caused more conflict of interest for Plastic Surgeons than any other. As with all surgery, Reconstructive Plastic Surgery was significantly curtailed for some months at the start of the pandemic and Plastic surgery is one of the few specialties where a significant proportion of practitioners are in majority or whole time private, cosmetic practice. In a judgment on a cosmetic surgery case in the last few years, a senior coroner in the United Kingdom stated in his judgement that, ‘Surgery should be about safety, not what you can get away with.’ Plastic Surgeons around the world, agreed and put their patients’ and staff's safety before their income and the vast majority stopped operating. Cosmetic surgery and medicine halted. In some countries for weeks, in others, for months. The re-start of cosmetic surgery has come at different rates around the world and, again, the vast majority of Plastic Surgeons have put safety before profit.

Surgeons are very often highly driven, highly intelligent and highly competitive individuals. Plastic Surgery remains one of the most sort after specialties to enter and to get a place in training you have to compete at a very high level. That behaviour, learnt or innate, usually becomes submerged as we spend the next 15-20 years from entering training, learning our ‘craft’. In those years we compete with ourselves to be the best surgeon we can be. However, once becoming an attending/consultant the competitive trait can start to re-emerge. Surgeons may then start to compete for facilities (including patients), academic position and/or for money. That manifests itself as friction with ‘competitors’ at best and conflict at worst and may involve individuals inside and/or outside the department, hospital, associations and between specialties nationally and internationally. Surgeons can be masters of cloaking interpersonal conflict as a conflict of competing interests. The same behaviour has been shown during the Covid crisis between neighbours with grudges to settle, informing the police of their nemesis’ antisocial behaviour. Surgeons are only displaying normal human behaviour but such arguments are almost always immensely destructive. If such conflicts happen in industry, one party would swiftly be ‘let go’ with their car and a severance package. In surgery, that rarely happens and careers and departments can be destroyed by the feuding. However, this is not new behaviour. Gilles and McIndoe were not immune from rivalries but, until the arrival of email, a letter had to written or dictated, typed, signed and then put in the post to be collected. What we would now call that a ‘cooling off period’. Now, in contrast, we have social media and the ‘send’ button allows immediate, angry responses to be sent that would have ended up in the wastepaper bin 20 years ago.

Unfortunately, as a consequence, there has been well publicised friction, competition, rifts and even legal cases between some national and international Plastic Surgical organisations. In spats such as these, the loser is the specialty. Conflict that becomes evident to ‘outsiders’ provides an opportunity for them to move into territories left undefended by those consumed by ‘righteous battle’. The result is that Plastic Surgeons perceive, and may well have, ‘lost’ work to other specialties.

The last decade has seen turmoil in the European plastic surgery associations, some of which have teetered on the verge of extinction and others have lost sight of what their purpose is. Each association has clear strengths and the specialty will gain if they all play to their collective strengths rather than compete. If competition continues, unless societies merge, others will benefit and the specialty will suffer. EURAPS has developed an excellent reputation for being THE European showcase for the best research in the specialty but it was, and perhaps still is, viewed as an ‘old boys’ club. The executive committee has made great progress in opening out membership to the young brightest and best academic plastic surgeons. It will, however, continue to be competitive to join EURAPS and membership should be viewed for what it is, an accolade for the best plastic surgeons in Europe, both academically and for those who have been influential in furthering the specialty.

The Covid crisis may lead to more fracturing of the EU than caused by Brexit. The United Kingdom left the European Union at 11pm on the 31^st January 2020 but all European legislation in force prior to that date was already enshrined in the Law of the United Kingdom. As a result of Covid19 and Brexit, Europe is now in ‘uncharted waters’ and there is no way of predicting the impact upon our specialty and our patients. Conflicts of Interest may arise as a consequence of Covid 19 and Brexit and it is essential Plastic Surgeons and our associations keep in mind our paramount responsibility, which is to protect our patients,

The Covid crisis has brought into the open one of the biggest conflicts of interest in Plastic Surgery. The ‘elephant in the room’ since the dawn of our specialty has been the inexorable increase in cosmetic surgery. ‘Cosmetic’ surgery being commonly referred to as ‘Plastic Surgery’ is very much double-edged sword for our specialty. In some countries, Plastic Surgeons are no longer trained in reconstructive Plastic Surgery and, in others, the majority of those who leave training schemes go straight into cosmetic practice. We have all seen cosmetic surgeons, doctors and other ‘practitioners’ boast about their material wealth and highly leveraged lifestyles. In the Covid crisis, their businesses have collapsed, as have millions of other small businesses. In previous generations, those Plastic Surgeons who went into cosmetic practice were frowned upon by those in reconstructive practice but the perception seemed to be changing prior to the Covid Crisis, mostly due the social media presence of ‘Plastic (i.e. Cosmetic) Surgery with the perceived financial benefits it provides in our very materialistic world. Those individuals now have little or no income and the future is very uncertain. Few will be able to step straight back into reconstructive practice and we will almost certainly see a rise in financial difficulties and mental health problems. Financial motivation is a very bad excuse in a court of law for performing cosmetic surgery at a time when there is definite risk of harm to a patient who undergoes ‘cold’ surgery, even if they have been fully consented. If complications occur, the patient will be exposed to much greater risk during the Crisis. The world will be a very different place in a few months’ time. Not every organisation, company and practitioner will re-emerge at the end of this crisis.

Our specialty has to decide how we reach an accommodation on this very active conflict of interest between the reconstructive and cosmetic branches of our specialty. If there is no return to the ‘boom’ days, will there be barriers set up by those in reconstructive/academic practice to prevent cosmetic plastic surgeons returning to reconstructive practice, especially if they are perceived as taking jobs from our surgeons in reconstructive training?

Disclosures of conflicts of interest are now required in every presentation and scientific publication. They are displayed at the start of every presentation but at the end of every publication. Many speakers on the international circuit use their disclosure slides as blatant adverts for their printed literature, videos and equipment, even if they are not associated with the presentation they are about to give. The multiplicity of international meetings and social media give a vehicle for developing an international presence as an ‘expert’ and, on occasion, can lead to Plastic Surgical ‘stardom’.

What is more important to the audience/readership, however, is the history of how a surgeon has reached their standpoint, especially if presenting the findings of research. The appearance and rise in the numbers of cases of Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) highlights this area of conflict of interest. Any new disease leads to be a rush to publish theories of causation. However, with all new, rare diseases, there is a paramount need to build a full picture of each case and form international collaborations to collect as much data as possible. Collaborations did indeed start when BIA-ALCL was recognised, and still continue, but theories about the cause of the disease were published based on observational studies from which causation was postulated but with no testing or proof. These theories were picked up by the media. This almost amounted to the scientific equivalent of ‘fake news’. It is very hard to shift perceptions once they have been published. We only have to look at the Anti-Vaccination publications to see the damage, which follows from publishing heart felt, but untested, theories of cause and effect. At present, there is no accepted theory of causation of BIA-ALCL, although an inflammatory pathway does seem to be involved.

We all have biases, but as doctors we are trained to not let them influence our judgment. Almost all Plastic Surgeons will have had an allegiance to a particular implant manufacturer and, probably, to a type of implant. That alone may produce a bias, if not a conflict of interest. If, however, a surgeon, department, clinic, hospital or clinic has had any paid or unpaid association with a manufacturer that may generate a potential, powerful conflict of interest. Our duty to our patients as Plastic Surgeons under our duty of candour is to declare any conflict of interest that may influence our choice of treatment. There is, therefore, a compelling argument that any associations must be declared at the start of every presentation and paper published on the subject of BIA-ALCL. Plastic Surgery, as a specialty, will suffer from accusations of protectionism and double standards if we fail to be seen to be completely open and honest.

There is, despite the problems discussed, a solid foundation for cooperation internationally, which should be able to see the specialty through any difficulties. We are a very small specialty compared with many and there is will welcome for most in any foreign city they visit, especially once travel becomes easier after the pandemic.

The ability for Plastic Surgery associations in Europe to find consensus was exemplified in the negotiations leading to the CEN European Standard on Cosmetic Surgical Services and Cosmetic, Non-Surgical Medical Services. The success of this venture, which was the first for any area of medicine in Europe, would have been impossible without the excellent relationships created in our specialty in Europe The CEN Standards were sponsored by the Austrian Society of Plastic, Aesthetic and Reconstructive Surgery and produced under the direction of the Austrian Standards Institute by hard won consensus. They provided a framework by which patients in every EU country, and corresponding state, could assess every aspect of the service they receive. They set out minimum standards, which surgeons and businesses should provide. Unfortunately, it appears they have been withdrawn by CEN.

The same cooperation and spirit of consensus continues internationally with Memoranda of Understanding between international organisations being signed. Whether ‘peace breaks out’ between the Aesthetic and the Reconstructive Associations remains to be seen but, if the radical changes in the delivery of post graduate medical education brought about by the Covid pandemic are a sign, there is a hope of closer cooperation. Plastic Surgery may be a small specialty but it is more than big enough to put the past behind us and extend that hand. To plagiarise John F Kennedy from his Inauguration Speech. ‘Ask what you can do for your Specialty, not what your Specialty can do for you’. It seems to be an excellent mantra for all Plastic Surgeons, especially at this time.