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Dr William N Goldsmith and Dr Hare

Interviewed by Dr Victor H Witten June 1 1960. London.

Dr Witten: What I am asking is whether the specialty of Dermatology and here I think of it locally, as you know it, is improving or whether it is getting worse, or whether you think it is at a standstill. Dr. Goldsmith over the many years now you have been in practice and associated here at the Hospital, what's your feeling about this?

Dr Goldsmith: I don't think there's been a very great difference. I think that Dermatology has always held a rather low place in the general estimation of those responsible for medical education. If anything, I think there has been a certain amount of improvement,for instance, we are included in the introductory course, the first course that the students take when they begin their clinical period so that it does seem to be conceded that Dermatology has some fundamental importance. But then there seems to be a gap after that, not merely in the attendance of students but after that stage General Physicians and, after all the curriculum is largely decided upon and planned by the Professors of Medicine and Surgery nowadays, and the Dean perhaps, but mostly the Professors of Medicine and Surgery, and in general they still seem to assign a rather low place to Dermatology. The General Physicians appear to consider that they for instance, are perfectly capable of examining candidates both for qualifying and for advanced Examinations in dermatological subjects, whereas a Dermatologist is not considered capable of examining candidates in General Medicine. And that is rather a peculiarly unfavourable position for Dermatology to hold.

Dr W: How do you think this has come about. Why should it be that way. Have you been deserted?

Dr G: I think perhaps there is a feeling that the curriculum is heavily loaded and that emphasis should be paid to general principles, a phrase which is very much overdone, rather than to a lot of facts and specialities and so the General Physician and the General Surgeon is more important than any speciality.

Dr W: You said that you feel that Dermatology unfortunately has always been held in some low consideration. Why is this so? Why is our Specialty so rated: Who is at fault? Is it the individual as a personality, his education. What is it because I think only by knowing why, can we do anything to correct this situation.

Dr G: I think it may be partly a paradox that is just because Dermatology was so important it split off from General Medicine rather early, so that nowadays we have Neurology, Cardiology, Gastroenterology and so on, still dealt with by people who call themselves General Physicians. They are the General Physicians. Most of the General Physicians in fact have a leaning towards some speciality but they remain as an organization and a Medical School at Hospital, General Physicians, but the Dermatologist has separated off long ago.

Dr W: Do you think in this separating off that he has given up some of his knowledge of General Medicine?

Dr G: Yes. I think to a certain extent he has. Perhaps for that reason. I don't think he has given it up to the extent that the General Physicians think he has. In fact I think that most Dermatologists here, at any rate in their younger days, are still very good General Physicians but it is true that as one gets more senior one does get very rustyin General Medicine.

Dr W: Dr. Hare when you took over the Department had you been here with Dr. Goldsmith and Dr. Bettley?

Dr Hare: Yes I have been here for 10 years in the Department,

Dr W: So they knew you here in the School.

Dr H: Yes, I qualified here.

Dr W: So they knew you here in the School of Medicine.

Dr H: Yes I qualified here. I have been here for 20 years.

Dr W: And you didn't come in cold so that you might feel any antagonisms and animosities that they might have towards Dermatologists.

Dr H: No, I was part of the furniture.

Dr W: Well how do you think it has gone?

Dr H: Well it's very difficult to generalize. There are some of my colleagues with whom I barely meet at all. There are the common problems. There are others who perhaps for social reasons I know better or perhaps I was with them in the Army and so forth who do call me in and their problems are very interesting and we can often help one another a great deal. But it is strange that in a Hospital of this size that there are relatively few occasions upon which we are called to the Wards to see a problem on which we could contribute. But as I say, it is difficult to generalize. Some people do and some people never seem to think about this as being able to contribute significantly.

Dr W: Do you have a feeling that as a Department and as individuals that you are respected as Dermatologists?

Dr H: Yes. I think we could fairly claim that and on occasions we do turn up something quite spectacular and prove our reputations at the time. By and large I don't feel very happy about our position. I think we could contribute a great deal more given the opportunity if we were invited more into ...

Dr W: What do you think you might do now, as a younger man, a productive person, you have been here for years, now faced with this almost emotional problem you might say, if you allow it to, to raise now the standards of your Department or if your standards are good to bring them into the activity of the University and its other Departments. What might you do. What might be the steps ..

Dr H: Well I don't know that one can do any more than one has tried to do for some years by performing those functions as well as possible and giving a good service when asked to do so, maintaining the reputation of one's Department.

Dr W: Do you feel that you could use more time in the curriculum for teaching of the undergraduate students.

Dr H: That's rather a subtle question because it depends so much indeed on the whole structure of the curriculum and its relevance to Examinations. What type of doctor are you trying to make?

Dr W: No, I bring it up here because in the United States in most Institutions, most Medical Schools, insufficient time is given to the teaching of Dermatology.

Dr H: Yes.

Dr W: It's often a very tough fight with the Curriculum Committee to get more time. And this is, I think, a very important beginning to have adequate time for teaching and to corelate it with the other Departments. Are you able to achieve this do you feel?

Dr H: No. I think we could do with more time, not compressed time, I think time over a period, such as perhaps is envisaged here in the future. In other words, I don't think we should have very concentrated teaching necessarily but they might have it continuously throughout their clinical career and we might appear at various stages instead of having a separate course in Dermatology or a set of Lectures, we might be much more integrated. We do now feature in some lectures on therapeutics where there are Boards, as it were, of Specialists speaking shall we say on steroids or antibiotics and so that I greatly welcome. But I think we could feature in other ways, I envisage even revolutionary things like talking to people during their gynaecological careers, about vulval lesions or when they are studying gastroenterology they might start in the mouth and learn something about the things we see, and so what I would hope to see is great integration into the teaching, not as I say a concentrated course but as part of the general structure of teaching as the student goes through the Medical School.

Dr W: Well, perhaps I was unfair. I challenged you in the beginning. I was really bringing to you what I think might be the position of Dermatology in the States. Maybe this isn't true here at all and I put you on a peculiar defensive.

Dr H: No I think we are probahly very much in the same position as you are.

Dr W: You think so. One of the things that has arisen in the States also is that there is in the selection of Heads of Departments, and let's say in Dermatology, the leaning apparently has been away from the clinical and more toward the scientific. Then one time to bring in as a Head of a Department a young man, or older, who has contributed in a particular scientific field and I might also venture to say, was able to bring with him a certain amount of monies from the various granting agencies. Now this begins to turn towards an imbalance of the clinical and the research and here I really would like to hear each of your opinions about how that ratio should be in a Medical School where Dermatology is taught to the undergraduate and even, Dr. Goldsmith, at the graduate level.

Dr G: I think there is a tendency here to more importance to be attached to research in making appointments. I don't think that money enters into it all and l would say on the whole that people who have done some research themselves and are still doing it, tend to make better teachers, or at any rate more inspiring ones, but that isn't by any means an absolute rule. Of course there are some extraordinarily good dogmatic or tutorial teachers who are completely unoriginal but I think perhaps in the undergraduate phase the first type of teacher is more useful than stereotype.

Dr W: Dr. Hare. What is your opinion about this. This is becoming a very important problem in the States. After all the question might be asked as how can one run a Clinical Department if one does not have someone well trained in clinical Dermatology?

Dr H: Well, I think the position in this country is to some degree prejudiced by money, the difficulty of making a living and the number of hours there are in the day. I mean the day when private practice was the mainstay of the doctor is past and he is very largely dependent on his salary from the Hospital side or if he is in a laboratory, from that side, and he has no longer the opportunity of making money in private work to any great extent. Now this I think probably has an important bearing on what one can attempt to do. I am not a very fast worker in any sense and I find it increasingly difficult to do any sustained laboratory work, while I have considerable clinical commitments in the Hospital ... and in private work and so I think it seems inevitable to me that in the future here we probably must have some dichotomy of clinical and research personnel to be on terms of time and energy and opportunity.

Dr W: Do you think that primarily a clinician should head up such a Department or primarily the necessary researchers should head up such a Department and have under him clinicians.

Dr H: No. I should have thought that the clinician in a Teaching Hospital should have charge of the Department. I may be prejudiced of course.

Dr W: Dr. Hare. How much time do you give to research and how much time do you give to teaching? What is your feeling about this question?

Dr H: Well I could answer your first one - I do very little teaching, at the moment. I may do a little more later but at undergraduate levels I do very little. My time is almost wholly research either clinical or laboratory. As regards I think what one of the things we were discussing earlier, you sort of rather divorced the two in your mind between the clinician and the research worker. This divorce, I think, is very unfortunate. You can't really do research in Dermatology or in any subject for that matter, unless you are clinically able to do research. And I mean in clinical subjects. I think it is a very bad thing to have this idea of divorcing the research worker from the clinic or the clinic from the research worker. One is supplementary and absolutely necessary to the other and I think that one should do both. Ideally, if one had the time in the week, one should take part in teaching the undergraduate clinical Dermatology, doing your own clinics and then running your own laboratory, and you could feed your own clinical material into your own laboratory. It's most important when you are doing work, as I have been doing in the past on patients, that I myself handle them completely because on occasions, I have had to take as many as 8, 10, 12 biopsies from one patient. I would never get the co- operation from the patient if I was not in medical charge of that patient. You can't always get this amount of material from any one patient but you stand little chance of getting any more than one or two biopsies from patients who are just farmed to you, saying Dr. X is interested in this. He will like to take a piece of your skin and that patient then feels that they are guineapigs and research is frustrated. I think it's much more the individual has to portray in two ways, rather than two people.

Dr W: I agree with you. I brought the question up in order to start the discussion, Dr. Goldsmith, over the years have you felt that the interest of an undergraduate student in Dermatology has increased or become less, that his attitude toward the Dermatologist in the Department has gained respect or lost respect in comparison to the other Departments?

Dr G: Well, that's extremely difficult to answer. I would say that on the whole the numbers coming voluntarily to the Department are fewer, so that in general I would say that perhaps interest has diminished somewhat. On the other hand, I think we have more individuals who, inspite of their small attendance, have become so interested that they come to say that they want to go in for Dermatology.

Dr W: It's always the latter which I think is the feather in the cap of the Head of the Department, really. The number of men. I have the feeling that it's really the small group of individuals who make up the problem create disinterest. Dr. Hare, what do you think the trend is of late. The trend towards the number of the students interested in going into Dermatology. Are they increasing in number?

Dr H: Oh. I couldn't really answer that. In my experience there is some increase there. Would have been a curiosity some years ago.

Dr W: You know, that in our own School the students will come to us and say that they know all about allergy of the guinea pig but they really would not know how to handle the care in the patient. This is because of the way that the entire approach of our School now is highly scientific. This is why I think that this, in a way, can be quite harmful and our men are being turned out to be more scientists than clinicians and it is because of this extreme attitude that I bring up the whole problem. I hope that the pendulum swings the other way and it may very well in the States soon. I was really anxious to know what was happening here generally. Are Schools becoming more scientific minded that turn out more the teacher, the Professor of Medicine or are they really turning out clinicians as well, worthy of the name?

Dr H: I am sure the trend is increasingly scientific and this School perhaps is unusual in tending to produce some very small number of General Practitioners and many more research people and academic doctors. It may not be so in other Schools in London. At the same time the aim of the School is to produce a clinical doctor at the end of his career and despite all their difficulties I think they succeed remarkably well.

Dr W: Are you full time?

Dr H: No.

Dr W: So you are allowed then to practice away from here.

Dr H: Yes.

Dr W: Are there Heads of Departments who are full time as far as you know in London.

Dr H: Most people are in the Medical School but in Hospital, not. In London nobody, neither Professor or Reader can be anything but full time. There is no question of that. That is fixed. Must be full time. For instance a Professor of Gynaecology doing clinical work and very little actual research, is full time - 100%.

Dr W: Dr. Goldsmith, as you look over the years and reminisce, after the change in the younger Dermatologist, there certainly was the day where you must have been solely the morphologist and now he's become a scientist as well, what is your reaction to this change in the practice of medicine, particularly Dermatology?

Dr G: Well, I think that the present day Dermatologist has a much greater understanding of his clinical problems and is a better doctor.

Dr W: And you think the patients benefited by that?

Dr G: I think there is a much higher standard of knowledge altogether than there used to be, but that's largely because there are these whole-time posts during the trainee period. You see these Assistants or Registrars as we call them, spend, say 7 years, perhaps whole-time in a Dermatological Department and they have a much greater knowledge than the old Dermatologist did when he started.

Dr W: I know I asked that because I think there are some places where the morphologic dermatology still remains very important in contrast to other Schools. Dr. Hare,do you think this is levelling off now here between the importance of being placed on the scientific as compared to the clinical? Some years it has been more toward the scientific. Do you think there is a levelling off now?

Dr H: No. Far from it. I should think it is getting increasingly scientific, increasingly specialized so that one person can't understand the other.

Dr W: Do you think the clinical training of the Dermatologist is suffering because of this increasing scientific attitude.

Dr H: I should have thought Dermatological training and opportunities were increasingly good. We still don't have facilities for many things we should like to do but it seems possible they will come along in time.

Dr W: As far as the attitude of the School as a whole is concerned you in Dermatology are getting more of the things that you require to carry on your clinical and scientific work.

Dr G: Yes, I think that's true. Yes.

Dr W: Well, I thank you

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