Type: Editorial
Published: 15-03-2019

Devil's advocate

Mark Lee MBBS FRACS,1,2 Mark Ashton MD MBBS FRACS1,3,4


Australasian Journal of Plastic Surgery
St Leonards, New South Wales, 2065



Specialist Plastic Surgeon
Subiaco, Western Australia


Clinical Professor of Surgery
Department of Surgery
University of Melbourne
Parkville, Victoria



Chairman, Professorial Plastic Unit
Epworth Freemasons Hospital
East Melbourne, Victoria

Name: Mark Lee
Address: Australasian Journal of Plastic Surgery
Suite 503, Level 5
69 Christie Street 
St Leonards, New South Wales, 2065
Email: [email protected]
Phone: +61 422 811 105
Citation: Lee M, Ashton M. Devil's advocate. Aust J Plast Surg. 2018;1(2):1–2.
Accepted for publication: 26 February 2019
Copyright © 2019. Authors retain their copyright in the article. This is an open access article distributed under the Creative Commons Attribution Licence which permits unrestricted use, distribution and reproduction in any medium, provided the original work is properly cited.

Keywords: surgeons, attitudes, dissent and disputes, plastic surgery, publications
Topic: Attitudes

A ‘devil’s advocate’ is a person who expresses a contentious opinion in order to provide debate or test the strengths of an opposing argument. The concept originated in the sixteenth century Catholic church when, upon considering a candidate for sainthood, Pope Sixtus V appointed a lawyer to act as advocate for the ‘devil’. The advocate’s job was to raise all conceivable objections to a candidate’s beatification and canonisation.1 The advocate was charged to be a dissenter, to find evidence of anything, however trivial, that may be used to argue against a candidate’s elevation as a saint.

By appointing a single advocate the Pope avoided the outcome of a more modern concept known as ‘groupthink.’ Coined by psychologist Irving Janus in the 1970s,2 groupthink refers to decisions made by a group of people, usually from similar backgrounds, when pressure is placed on would-be dissenters to remain silent about their doubts. The group thus enforces the (faulty) concept that it is unanimous and infallible, resulting in an illusion of unity. A famous example of the negative consequences of groupthink is the Y2K problem when a group of programmers feared that the coding of calendar dates would cause chaos when the 1 January 2000 arrived.

Is our speciality vulnerable to groupthink? Probably so. We are a relatively small and cohesive group, from similar backgrounds, who believe in our own inherent morality.
Early in Mark Lee’s training it seemed as if every plastic surgeon in his far western state had purchased an expensive pulsed dye laser for their offices. A few years later they were all gathering dust (and interest payments). Is this happening now with cryolipolysis machines? Time will tell.

A long retired, and very respected, mentor of the same co-editor continued to use smooth round implants when all the young guns were using textured tear drop implants. Now Breast Implant ALCL has swung the pendulum back. This same mentor also used a Tennyson Randall triangular flap for his cleft repairs when all around him had gone to the Millard repair. This repair was uncannily similar to the now prolific Fisher repair.

Other examples of groupthink could include:

  • textured implants and capsular contracture
  • cleft palate repair and midface growth
  • local anaesthetic with adrenaline in the digits
  • rhinoplasty tip grafts
  • fat grafting in radiation affected areas, and
  • facial fillers as the answer to facial rejuvenation.

Surely there are many more.

It is important that we always remember that some of the techniques we are using today may be modified or even totally reversed in time and so it is imperative that we, as a specialty, continually reflect on what we do. We must all challenge accepted dogma. We must allow those with dissenting opinions to speak up.

Perhaps our meeting moderators should be asking for a devil’s advocate after every presentation. This is particularly important after the travelling rockstar plastic surgeon, armed with a slick, animated, power-point presentation introduces a new, untested, non-peer reviewed technique. Not infrequently, our older mentors, with experience behind them, are the only ones questioning a new technique, quietly shaking their heads at the back of the room.

That being said, we know that knowledge does not advance in a straightforward, linear manner but as a series of ‘staircase steps’ in which there is rapid advancement and the introduction of seemingly radical new ideas into a background of previously stable and accepted scientific norms. Often, these new ideas are confronting and draw scepticism.
But the difference is that valid advances and new techniques are able to withstand such questioning and are able to win over even the most vocal critics. It is not the act of questioning which is at fault. Indeed, the questioning of new and established surgical dogma is integral to any worthwhile scientific discussion. Hopefully this journal can in some way be our specialty’s advocatus diaboli.


The authors have no financial or commercial conflicts of interest to disclose.


  1. Beccari, C. Beatification and canonization. In: The Catholic Encyclopedia. New York: Robert Appleton Company, 1907. [Cited 20 February 2019]. Available from:
  2. Janis, Irving L. Groupthink: psychological studies of policy decisions and fiascoes. Second ed. Boston: Houghton Mifflin, 1982.