The Changing Face of Orthopaedics – and the Face in the Mirror

Twenty years in the NHS have transformed the way we operate, train and lead. Sometimes, however, it takes an old colleague and a conversation about grown-up children to make us notice how much we have changed too.

I went to the British Orthopaedic Association Annual Congress in London expecting to think about orthopaedics. I came away thinking about time.

There was plenty of clinical and professional substance. I heard the British Orthopaedic Directors Society discuss the financial questions surgeons rarely receive formal training to answer. I listened to the British Hip Society explore the RACER trials and the role of robotics in arthroplasty. The BASK session on revision knee surgery tackled the difficult decisions familiar to anyone working at the complex end of joint replacement.

All were useful. All offered something to take back to clinical practice.

Yet the most memorable part of the congress happened outside the lecture halls.

It was seeing former medical students and junior doctors – people I remembered at the beginning of their careers – returning as registrars and consultants. It was meeting contemporaries who are now established surgeons, departmental leaders and trainers in their own right.

Then there were the conversations with colleagues who had been relatively new consultants when I first met them. Once, we might have discussed fellowships, examinations and finding our feet. Now we compared the ages of our children. Some spoke about children at university. Others talked about pensions, changing job plans and preparing for retirement.

Nobody announces that a chapter has ended. The conversation simply changes.

Twenty years, almost unnoticed

In August 2027, I will have been a doctor for 20 years. Every one of those years will have been spent in the NHS.

That milestone still feels faintly improbable. Like many doctors, I suspect I have measured my career less in years than in transitions: medical school to foundation training, junior doctor to registrar, trainee to consultant, colleague to supervisor, and eventually supervisor to the person others approach for reassurance or advice.

Medical careers are particularly good at disguising the passage of time. There is always another list, clinic, meeting, deadline or service problem demanding attention. We become accustomed to marking time through rotations, appraisals, revalidation cycles and school holidays.

Then, at a conference, someone you remember as a student tells you about their consultant post. A former junior colleague is chairing a session. Someone else asks whether you have looked properly at your pension.

Suddenly, two decades are standing in front of you.

The NHS I joined

The NHS of 2007 was hardly simple or unpressured. But it belonged to a different era.

The 18-week referral-to-treatment standard was being introduced, carrying an ambition that patients should move from GP referral to definitive treatment within a clearly defined period. Today, that same constitutional standard remains, but the context has changed dramatically. By June 2025, England’s elective waiting list contained approximately 7.37 million pathways, with trauma and orthopaedics among the specialties carrying the greatest burden. (NHS England)

The clinical environment has changed too. Paper notes, handwritten operation lists and radiographs carried between meetings have increasingly given way to electronic records, digital imaging, virtual consultations and data dashboards. Enhanced recovery has altered the experience of joint replacement. Registries have become central to surveillance and improvement. Robotics, once easy to dismiss as an expensive curiosity, is now important enough for major randomised trials and plenary discussion.

The 2026 Congress itself captured this perfectly. Its official theme was “The Changing Face of Orthopaedics.” (British Orthopaedic Association) The programme ranged from robotics and large clinical trials to revision surgery and the financial realities of a surgical career.

Technology has changed what is possible. Data have changed what is measurable. Patients, rightly, expect to participate more fully in decisions about their care.

But progress has not removed pressure. It has often changed its shape.

From apprenticeship to accountability

Training has evolved significantly over the past 30-40 years but so many changes have occurred in the last 20.

The informal apprenticeship model has become more structured, documented and competency-based. There is greater attention to supervision, consent, human factors, patient safety and demonstrable outcomes. These are important gains.

At the same time, trainees face pressures that my generation did not experience in quite the same way: intense competition at career bottlenecks, fragmented working patterns, reduced continuity with trainers and anxiety about whether progression will happen where – or when – they hoped. I haven’t even thought about the issues with pay and the significantly greater debt that junior doctors now carry.

The latest GMC workplace research reflects this strain. In its 2025 Barometer survey, only 55% of doctors reported satisfaction with their day-to-day work, while 20% were considered at high risk of burnout. Twenty-two per cent said that leaving the UK profession was the career change they were most likely to make in the following year. (General Medical Council)

Those figures should trouble anyone with responsibility for leadership or training.

When I see former students succeeding, I feel enormous pride. But pride should not make us romanticise the route they have taken. Our responsibility is not simply to admire the resilience of the next generation. It is to create a profession in which extraordinary resilience is not required merely to remain.

The conversations change because we do

The BODS session on finance felt especially appropriate. Medicine prepares us extensively for clinical uncertainty but rather less well for the practical stages of a career: mortgages, school fees, pensions, changing family responsibilities and eventually retirement.

These subjects can feel peripheral when we are young. Later, we realise that they influence whether experienced clinicians can continue to contribute – and whether they want to.

NHS workforce policy now explicitly recognises the importance of flexibility, retention and late-career planning. NHS England has advocated flexible retirement, adjusted job plans and a “decade of retirement” approach that allows experienced doctors to reduce or reshape their commitments rather than reaching an abrupt stopping point. (NHS England)

That matters for services, but it also matters at a human level. A surgical career should not have only two settings: full throttle and finished.

Perhaps that is one of the lessons that becomes clearer with time. Careers need seasons. The contribution of an experienced surgeon may gradually shift—from operating volume towards judgement, mentorship, complex decision-making, teaching and organisational memory. A mature institution recognises the value of all of these.

What has not changed

For everything that has evolved, the foundations of the work remain remarkably familiar.

Patients still arrive frightened and place their trust in us. Complications still carry a human weight that no dashboard can fully represent. Good surgery still depends on preparation, judgement, technical discipline and teamwork. Younger colleagues still need someone who will teach them, advocate for them and occasionally tell them that a difficult day does not define their ability.

The NHS itself remains a paradox: pressured yet indispensable, frustrating yet full of extraordinary people. I have spent my entire professional life within it. That does not make me blind to its problems. If anything, longevity makes the problems harder to ignore.

But it also makes the achievements harder to dismiss.

For nearly two decades, I have watched teams adapt repeatedly – to new technology, reorganisations, workforce shortages, rising demand and a pandemic. Much of what keeps the service functioning cannot be found in a strategy document. It exists in relationships, professional generosity and the willingness of people to step forward when the system is stretched.

The face in the mirror

Conferences are ostensibly about looking ahead: the next trial, the next implant, the next technique and the next model of care.

This one also made me look backwards.

I thought about the doctor who entered the NHS in August 2007, and how little he understood about the career ahead. I thought about the students and junior doctors who have since become colleagues. I thought about children growing up in the spaces between on-calls, clinics and operating lists. I thought about surgeons who once seemed far ahead of me now discussing how – and when – to step back.

That is not melancholy. Or at least, it is not only melancholy.

There is gratitude in it: for the patients who trusted me, the colleagues who taught me, the trainees who challenged me, and the privilege of belonging to a profession whose work genuinely matters.

In August 2027, I will reach 20 years as a doctor, all of them in the NHS. The service has changed. Orthopaedics has changed. The people around me have changed.

And, somewhere between the operating theatre and the conference hall, I have changed too.

Perhaps that is what a career really is: not a ladder climbed or a destination reached, but a long series of people, responsibilities and conversations. At first, we discuss exams. Then jobs. Then children. Then pensions.

And if we are fortunate, we eventually realise that while we were busy building a career, we were also living a life.