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Dr Louis Forman

Interviewed by Dr Victor E Witten June 30 1960. London.

Dr Witten: You began in Dermatology when?

Dr Forman: I began in Dermatology in about 1928/29. But previously I had been in charge of some dermatological beds in another Hospitaloutside Guy's and the Hospital actually was visited by Dowling. Dowling was in fact a Medical Registrar. I was on his Firm.He was one of my Teachers. And then he swung over to Dermatology and became Barber's assistant. He used to visit this Hospital which is 3-4 miles away, and that is where I came into contact with him.

Dr W: Well at that time you remember the position of Dermatology and the Dermatologists in the sphere of medicine. Can you compare it then with now. And why do you think it has changed?

Dr F: I think Dermatologists have become very much more significant than they ever were. At Guy's we had Barber, the first pure Dermatologist and I suppose he would have been appointed in about 1920 to the Staff of this Hospital. Before that the Dermatology was the responsibility of the fifth assistant Physician. There are five assistant Physicians and the new man was automatically interested, or responsible if you like,for the Dermatology. Those people have included very considerable names. People like Xilton Faye, Addison who was intensely interested in dermatological proBlems, Sir William Gull the man who described myxoedema, and so on, they were all intensely interested in dermatological aspects and they were all very good. Excellent Dermatologists. So that you can see that the idea at Guy's, until comparatively recently I think, would be that Dermatology was a branch of medicine and therefore should be practised by General Physicians who knew the background, who knew their constitutional medicine so to speak. And Barber was the first pure Dermatologist. Barber had been a Medical Registrar,that is to say he had been responsible for the teaching of medicine for a period of time, and of course, Barber was an absolutely first class Physician. He was a brilliant General Physician. So that that has perhaps set a pattern really to the dermatological approach in this Hospital. Dowling was Medical Registrar, I followed Dowling. I was a Medical Registrar and really what attracted me to Dermatology was Barber's approach to the disease. I mean there was a man looking at a skin and he could look inside. One of the few people who could corelate what he saw. And he would corelate it with the whole patient, the constitution of the patient. Made it very fascinating. Very interesting. Very exciting indeed. There was a bit of a hangover in Barber to the old ideas of the metabolic background of many eczemas. And he was quite right of course. He always talked about the gouty eczema. That's a very real thing in a middle-aged person. Metabolic eczema of the hands and the feet in the middle-aged person. Very real. We have quite a number of them with raised blood uric acid and the thing goes away with salicylates and so on. It's quite interesting.

Dr W: Well, from Barber's time on how do you think now that Dermatology is different in its standing?

Dr F: I think it's different in many Hospitals by the recognition in the Medical School that it's necessary for the medical student to have a better knowledge of Dermatology. You see there is no need for them to have passed through the Dermatology Department or had any contact at all with the Dermatologist in many Hospitals and many Schools. We have made it obligatory for every medical student to spend a definite time in the Dermatology Department. We try and interest them in the subject by giving them in their very earliest time when they are just coming into the clinical period, we give them all three sessions. I try to interest them in the dermatological manifestations of constitutional disorder you see. That has been a very considerable improvement in medical education of the student. On the whole our Staff has enormously increased. When Barber started he had a Registrar, two part-time Registrars and that's all. He had a table and a desk and a chair and that's all. We haven't got very much more than that at the moment. As a matter of fact this Hospital is very poorly supplied with facilities, and accommodation. We feel rather sorry about that. We have tried to obtain appointments for our people and our junior staff in the School departments. In fact I had a rather nice scheme which I'd hoped to start to accept just after the War and there was a good deal of expansion you see, of all the medical services. The War started in '45. We had a National Health Service started in '48 and that was associated, those three years, with terrific expansion of the whole medical service of the country. We had a large number of people coming back from the Services fairly well trained and so on and they enter the Hospitals as Registrars and so on. I'd hoped that we would have here about three or four people doing part-time work and each one being seconded to a Medical School department. One would go to the Pathology Department the other would go to the Biochemical Department and I'd hoped that if they could work under recognized experts you see, in these various special departments, that they would be able to do what you've done for years, and what's happening here now, that is to develop a scientific Dermatologist, a man who has laboratory technology and so on, a method at its disposal. Well, that hasn't worked out, not here, nor has it worked out anywhere in London except perhaps it's coming in the Institute of course. We are getting more people there working in the laboratory learning their scientific methods, at the same time they are practising Dermatologists in that they have definite clinical duties you see. But you of course, have had those sort of people for years, haven't you.

Dr W: Well its certainly been on the increase.

Dr F: I think so. Well the John Hopkins - I was very impressed when I was there 5,6 7 years ago, not in Dermatology but I mean in General Medicine.

Dr W: Well. This is one of the things I wanted to bring up. Is it this trend for the scientific in the various departments, is increasing so rapidly and with so much force,and is carrying over into Dermatology,that sometimes the selection of the Head of the Department may be more on a scientific prowess than his clinical. What's your feeling about this?

Dr F: Well. I have very considerable sympathy really with that view. Most Dermatologists in this country have been I think clinically very good. And that is to say their clinical practice has been very extensive. They have had to rely upon their clinical sense and knowledge and memory so they've been, as clinicians, I think, quite good. As far as I can compare them with people in other countries. But when it comes to the setting up of an investigation or the carrying out of any laboratory investigation then they've not been able to do it. They don't know how. They haven't thought along those lines.

Dr W: Yes. You're favouring more the scientific with the clinical. I'm pointing out that in some instances it is the scientist who is now coming in as the Head of the Department, brings with him notoriety to the School, he brings money to the School, in the States, and the question is if clinical Dermatology in the eyes of Medicine may not suffer because of this. In other words, would you be happy if you were headed by a scientist rather than a clinician.

Dr F: It depends really what stage your at. I think that, let's take our own case here, we've recently or are going to appoint a Professor, aren't we, at St. John's. Shall we say that among those in the field or considered for this appointment, there was one man, an excellent clinician, there was another man who was much better known really for his laboratory work. At the same time of course, he had had clinical responsibilities and clinical training and the question arose, would it be better to have a scientist as such, or not. My feeling was, that probably if you could get a suitable person, the scientist would be better. You have there a whole galaxy of excellent clinicians. There's no need really for a man whose interest or primary clinical whose knowledge was based on his memory of dozens and dozens of cases and hearing what people thought and so on. Indeed, you 've got that well covered. You have probably there at least six or seven or eight excellent clinicians who could instruct, who could carry out clinical trials perfectly well but we haven't got the people whose knowledge of say biochemistry was......

Dr W: Yes. But let me put it around the other way. If you had a clinician who knew something of the scientific and could bring into the Department the scientists, if that particular person isn't in a better position to know what is required at the undergraduate and graduate level in dermatological ..

Dr F: Oh, yes. Well of course, the thing I have been talking about is postgraduate - the Institute of course is entirely postgraduate at St. John's. There's no undergraduate teaching there you see. Undergraduate schools, perhaps another story. Part of the function here is to train people to be able to treat patients, I mean they have definite responsibilities. Clinical responsibilities. We are not so much interested perhaps in turning out a scientist. All these chaps who come here have got to be responsible doctors haven't they.

Dr W: Well the trend in some of our Schools is toward the more scientific.

Dr F: Yes. I can appreciate that. ... Hopkins it was particularly well marked, of course.

Dr W: Let me ask you. The number of students who go through training and the number who are able to pass the Examinations to go into their Consultant Specialist training, how many of them select Dermatology. I understand its a small percentage. Why do so few select Dermatology?

Dr F: Well I think that the opportunities of course are so comparatively small. They have very few opportunities. The number of Departments are comparatively few. I've forgotten the actual numbers of Dermatologists present before the War, and the actual numbers present now. Of course, there was a big expansion. After the War we had a large number of people who were trained in Dermatology who had been in the Forces, as you did They were supported of course by Government Grants and they were placed throughout the country. The Departments of Dermatology were started in Hospitals where they had never existed before. Throughout the whole country so that we had aimed really, I am beginning to remember the figures now of 4 per million would be a reasonable number throughout the whole country. Well let's say we have 50 million - 4 per million is 200 Dermatologists. Which are not very many, throughout the whole country.

Dr W: So you think then that the number selected is simply because they know that their opportunities are limited.

Dr F: Certainly, certainly.

Dr W: You don't think its because they have any disrespect for Dermatology.

Dr F: Oh. Lord. no. I don't think so.

Dr W: You don't think so. Do you feel that
Dr F: I think that they are guided entirely or many of them, some of course, as I was, would be interested by the personality of the teacher, you see.

Dr W: This is why I think it's so important that the undergraduate level where our most dynamic teachers might be if one is to attract into Dermatology, the good men. Maybe its not necessary in this country.

Dr F: Yes. I think that a teacher, or the personality of the teacher is important in any branch of medicine. Any branch, whether surgery, general medicine, neurology or anything. I could have easily been a neurologist. We had Charles Simons here who again was an excellent teacher.

Dr W: I appreciate this. This is why I think that there is competition always, at the undergraduate level to gain the interest of the student.

Dr F: Oh yes. Very much so. I'm sure that's important. But I think the scientist could do it just as well as the clinician. If the scientist using his skin reactions might be able to display reactions of nerve stimulation of biochemical reactions and reactions on the skin I think that if he was a sufficiently good teacher and demonstrator I think that he could just as well attract an undergraduate to Dermatology, just as well.

Dr W: Well let's say then that the respect for this person, if this person were called in consultation before the internists and the surgeons not only would he have to know the scientific but he'd have to make a very good clinical showing.

Dr F: I entirely agree with you. I see what you mean. But you're choosing rather extreme examples' you're going to have scientists, you mean that by a scientist you mean that somebody whose knowledge and interest and experience in clinical medicine is very small indeed. I don't take that view. By scientist .. my scientist would be a man who has had a very sound clinical training, who had a very considerable period of training in dermatology as well that he would be, say part-time, half-time in the clinics, half-time in the wards and that he would continue in his laboratory work for the other half of the time. Mind you he might have spenta year or two, or more, purely and absolutely in a scientific laboratory with very little clinical time during that year or two, but a good deal of his time would be in training and in subsequently clinical work. His contact would be very close. I wouldn't take somebody who had been so pure, somebody from the Bacteriology Department up here for example and say well now you're going to go into Dermatology,

Dr W: No you wouldn't. Give them three years of training and say well now you're capable of being the Head of this Department.

Dr F: Mind you, you have got to be a little bit careful there have been in many branches of medicine,that method has been eminently successful. It used to be done here - a man who was,although perhaps not quite so unrelated, but a man who was able to say to somebody now look there's no job you've been a surgical registrar, there's no job in general surgery, you must be now a Gynaecologist. And I've known that done on two occasions with excellent results. I've known it done, our best Orthopaedic Surgeon, an extraordinary fellow, who was more or less turned over to orthopaedic surgery. It doesn't necessarily follow that a man would be a failure, it depends very much just on his clinical ability. A man may have clinical abilities, may spend an awful long time in the laboratory it's true but he may still have clinical abilities. The trouble is of course that you got much better opportunity of judging a clinician's clinical ability because he's been longer at it, than you have of scientific individuals' clinical ability because he's not been very long at it. And you may fall down, make a complete flop. Don't you think so.

Dr W: Oh. I think this is so highly individual. And I think that if one selects men carefully and watches their training carefully that may work out. But I've seen just the opposite happen now and makes me dubious whether the man shouldn't be a good specialist to be the Head of the Department. He may have the good fortune to have all that is required scientifically and I think today one needs the balance between the two.

Dr F: I think so. You have to balance the two together.

Dr W: Of all the things that have happened since the War which may have benefited the place of Dermatology and Dermatologists in England what do you think are the most important things today that have raised this standard? Is it the rigidity of the Examinations which selects highly the men who may become Specialists?

Dr F: I don't know that the standards of the individual Dermatologist have been raised. Do you mean the way in which it is regarded in the Hospital? Well, I think that perhaps the War had an awful lot to do with it, you see. The curious thing is since the War came along the demand for Dermatologists went up enormously. I told you, in this area alone I must have had at one time more than 200 beds, well over, 250 perhaps. It was astounding how they were required. I think that made a big impression and it made a considerable impression on the people who were responsible for manpower, when they found that they were losing so many in factories, in the Forces, because of their skin diseases. They were laid low and they couldn't be got at. A skin disease on the hand would knock 'em out just as effectively as any serious disease. They were walking around, but they couldn't work. When every pair of hands were needed and counted, the demand ....

At this point the recording unfortunately finishes.

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