Aust. J. Derm. (1976), 17, 117
WHITHER DERMATOLOGY ?* H. R. VlCKERSf
Oxford, U.K. Having been closely involved in medical and dermatological administration most of my professional life, and in view of the widespread medical and political unrest in many countries, this is an appropriate time to consider the place of dermatology in medicine in the future, and how dermatologists can best contribute to the advancement of medical knowledge. The way medicine is practised in each country is determined very largely by tradition, and by political climate, but the broad principles should be common to all countries. The basic aim of all doctors must be to help the patient and to try to prevent disease. To understand the present situation in the United Kingdom, it is necessary to bear in mind the way in which specialization in Great Britain evolved. Diseases of the skin was probably the first of the special branches of medicine. Although the majority of men attracted to the skin were physicians, there were notable exceptions such as Jonathan Hutchinson who, although appointed Assistant Surgeon to the London Hospital in 1859, was also on the staff of the Skin Hospital at Blackfriars. There was a great upsurge of building of Voluntary Hospitals in the United Kingdom in the second half of the 18th century. These hospitals were staffed on an honorary basis by general practitioners having an interest usually in medicine or surgery. Some of them became particularly skilled and gave up their general practice to specialize. It is in this stage that the United Kingdom differed from the rest of Europe, because the man who became a specialist usually no longer saw patients direct, but only those referred to him by another practitioner. This became the established pattern in Britain. Since the specialists were not paid for their hospital work, they had to make their living in * Based on a paper read at the Annual Meeting of the Australasian College of Dermatologists, Adelaide, May 1976. t Honorary Consulting Dermatologist, Oxford. Senior Lecturer in Medicine (Dermatology), Royal Postgraduate Medical School, Hamm.ersmith, London.
private practice. Because they saw only patients referred by other practitioners, inevitably this meant that the number of specialists in any area was determined not by the needs of the populace, but by the amount of private practice available. Skin disease was much more common among the poor than the wealthy, so specialists could only make a living in large towns. Before the introduction of the National Health Service in 1948, there was no whole time specialist in dermatology within 100 miles of London ; all the wealthy travelled to " Harley Street ". These men worked very hard since, in order to become known to the general practitioners who referred patients to them, they did enormous out-patient clinics, often at many different hospitals. It is very much to their credit that, in spite of this, many of them made valuable contributions to medical literature. There was therefore, in Great Britain, in the first half of this century, a very small number of dermatologists compared with the rest of Europe. In those countries, the patients themselves consulted the dermatologist without necessarily being referred by a practitioner; nor was it essential for the dermatologist to hold an appointment on a hospital staff. A photograph taken at the annual meeting of the British Association of Dermatologists, held in Oxford in 1928, shows only 36 present. Another consequence of private practice on the early development of dermatology, was the great difference between hospitals in the time when they first appointed a dermatologist as such. If any one of the staff was also interested in skin disease, and was thereby increasing his income, it was unlikely that a dermatologist as such would be appointed. University College Hospital, London, appointed a dermatologist. Sir William Jenner, in 1859 but Addenbrookes Hospital, Cambridge, did not create such a post until 1929. This was the hospital situation when I was appointed Honorary Second Dermatologist to the Royal Sheffield Infirmary and Hospital in 1939. I had to make a living in private practice,
118
H. R. ViCKERS
and picked up fees for doing a syphilis clinic ; the gonorrhoea being looked after by one of the junior surgeons. However, I had joined the R.N.V.R. as a medical student in 1931, and was mobilized on the outbreak of war. It says a great deal for the faith of our elders, that long before the war was drawing to an end and when the outlook for our survival was not too rosy, they were actively engaged in considering the problem of medicine after the war, within the concept of a National Health Service financed by the state. It was reahzed that the old system of hospitals being dependent on raising private money could not survive. At that time, I, as a young consultant, attended several meetings, held usually at St. John's Hospital, to consider the future pattern of dermatology in Great Britain. Most of the discussion was centred on the training of dermatologists and whether or not a specialist dermatological qualification should be introduced—granted at the end of a statutory training period on the result of an examination. Already the ophthalmologists and oto-rhinolaryngologists had introduced a Diploma in their respective subjects. We had several very full meetings in which the views of the young were sought, since any changes would have a much greater effect on their future. It was felt very strongly that since dermatology is a branch of general medicine and that in dealing with skin disease inevitably one encounters internal disease manifesting itself in the skin, it was important for any dermatologist to be trained initially in general medicine. It was therefore decided that a dermatologist should first of all obtain the M.R.C.P. and then be trained in dermatology. It is of interest that this is now the pattern in all the newer branches of specialized medicine—neurology, nephrology, gastro-enterology, cardiology etc. It was also felt that there was a real risk of downgrading our branch if we established a separate dermatological qualification. This is still the situation in Great Britain, i.e., there is no higher qualification for dermatologists apart from the M.R.C.P. in which skin questions may be asked, and dermatologists serve for a period as specialist examiners. A diploma has been instituted by the University of London, the object of which is to enable those who have completed the year's intensive course at the Institute of Dermatology (St. John's) and who come very largely from developing countries, to have some tangible proof of having reached a standard of proficiency before returning home.
This qualification, in the absence of the M.R.C.P., is not regarded in Britain as entitling the holder to apply for a consultant post. More recently, with the forthcoming removal of medical barriers between countries of the European Economic Community, the problems of recognition of specialist status are very real. In the past, one was recognized as being a consultant in any branch of medicine in Great Britain by obtaining a consultant post in open competition. This obviously is of no value to a young man who has done all the necessary training for a consultant post in Britain, but who then decides to work in another country in Europe. Without some proof of his ability, this could lead to difficulties and again, the introduction of a specialist examination was discussed. I was opposed to this and the reasons for taking this view are simple. In Great Britain now, the National Health Service is a monopoly employer, and it is almost impossible to make a living outside the National Health Service. If a young man spent at least four years training, say in dermatology, then had to take an examination in order to be regarded as a specialist, and failed, it would be impossible for him to make a living in dermatology. He then would have difficulty in getting into any other branch of medicine, as a trainee, because of his age. The situation now is that all trainee posts in all branches of medicine are inspected by teams appointed by the relevant Royal Colleges, and anybody who undergoes training in such an accredited post, having passed the M.R.C.P. provided he has satisfactory reports from his teachers, will be accredited as a specialist. In the United Kingdom, he will still have to ap}:)ly for consultant posts in open competition, but he will be able to work in Europe and go into private practice there, if he wishes. The evolution of the speciahst branches in the United Kingdom is relevant to our future. A dermatologist should be essentially a physician with a special interest in the skin. T'his view was ingrained in me by three dermatologists, all of whom had a great infiuence on me in my early years. Rupert Hallam, my original teacher, John Ingram who then worked in Leeds, and Geoffrey Dowling whom I had the very good fortune to get to know when I was working in London in 1939. During my 39 years in dermatology I have seen nothing which has made me wish to change this view, and having observed the development of dermatology and other branches of medicine in other countries, in separate isolated units or
WHITHER DERMATOLOGY ?
institutes, my original view has been confirmed. Dermatologists must work closely integrated in general hospitals. So many of the patients we see also have complicated internal problems. Many of the fascinating manifestations of disease in the skin I see are referred by other specialist members of the staff. This close link is impossible to establish in separate institutes or special hospitals. It is over lunch or in the common room of a hospital that important contacts are made. I also feel very strongly that we should make every effort to take an active part in the Grand Rounds and hospital chnical meetings. It is through this type of discussion that new advances, often relevant to our own problems, are aired, long before they appear in the medical journals. This leads to the next point, that is, the importance of interesting the basic scientists in our problems. Fortunately, this has recently become much easier with the introduction of new techniques enabling the skin to be used as a valuable investigative model. It is much better to cooperate with an active basic sciences department, than having one's own basic scientist, e.g., biochemist or immunologist, working isolated from his fellows in a dermatological department. Such links have been established in Oxford and they are now bearing fruit. There is active cooperation with the microcirculation experts, the collagen experts, the immunologists, the M.R.C. leprosy research centre at Mill HiU, the biochemists, and so on. With regard to advances peculiar to our own branch, we have to encourage research in histopathology, photodermatoses, genodermatoses etc., but these specialized units should be attached to selected dermatological departments, and each department should not try to have its own photokinetic king or geno dermatologist. Such collaboration is inevitably time consuming, and may be difficult to fit in with very heavy clinical commitments. One of the advantages which many of us welcomed, arising from the National Health Service in 1948, was that we were no longer entirely dependant on private practice for making a living. The National Health Service salary not only provided our bread and butter, but enabled us to find time to take a more active part in hospital activities. Another of the benefits of the National Health Service was the establishment of departments in hospitals where there was a dermatological need. It has been possible to recommend the establishment of new viable posts throughout the country, and gradually
119
to restructure existing ones to abolish the old problem of peripatetic dermatologists who had no real allegiance to any one hospital. In Great Britain with the present financial stringency, with the exception of finding a very wealthy donor, the only way we can estabhsh University Departments of Dermatology in future, is for the dermatologists to demonstrate to both their fellow clinicians, and basic medical scientists, that dermatology has an important role to play in the advancement of medical knowledge. To establish a clinical chair in a University such as Oxford now requires about half a million pounds, and one has to have a cast-iron case in order to extract this sort of money from a tight university grant, in competition with all the other worthy claimants. My view is that dermatologists should remain actively integrated with general medicine and basic science departments, and there is still great relevance in the opening of the preface of the Fifth Edition of Frasmus Wilson's book, " Diseases of the Skin", published in 1863, " Cutaneous medicine is an important branch of general medicine : it embraces every form of pathological change which takes place in the external surface tissues of the body. It demands, for a thorough comprehension, all that appertains to the philosophy of general medicine, as well as the particular knowledge which belongs to the dermal textures. It presents to our notice in the double sense of a disturbance of the general organism of the body, and as a disturbance of the special organism of the skin. It includes all that concerns the health of the individual: in its special or local character it comprehends, in an equal degree, all that belongs to the organism of the part:—its vessels with their blood ; its nerves with their governing principles; its glandular apparatus with their secretory functions ; and its various component tissues ". This is therefore the way ahead for our branch. Although working in isolated units has many attractions, the ultimate result would be to stultify the expansion of dermatology and eventually lead to dermatologists reverting to " pimple doctors ". To deal briefiy with an aspect of British medicine which is probably of concern to other countries at this time of political unrest, the National Health Service. Most young consultants welcomed the introduction of the National Health Seivice in 1948, for the reasons already mentioned, and the very real advantage of being able to treat the patient without having to take the cost of treatment into consideration.
120
H. R. ViCKERS
By the system of whole-time or part-time Unfortunately this coincided Math infiation, contracts, the consultants were able to do a and from every point of view has, in my opinion, varyihg amount of private practice, being paid been disastrous. There has been a mushroom for their hospital work proportionately to the growth of all types of consultative committees, time they spent each week in the hospital. This and not only are these enormously wasteful of worked very well in the first few years, but valuable professional time, it is now almost with the new advances in treatment and impossible to get any decision on a problem. diagnostic techniques, costs escalated and Paper is circulated in vast quantities ; the old successive Governments were unable, or days when one could drop into the hospital unwilling, to finance the service adequately. administrator's office and discuss difficulties Apart from difficulties arising from delays in with him have gone since he is always " in either buying modern, or replacing worn out committee ". The service is foundering under equipment, the salary scales of all grades of the dead weight of consultative committees staff failed to keep up with the increase in the divorced from executive control. cost of living. There was difficulty in recruiting With the altering social and political climate nurses, secretaries, hospital porters etc. and all this leads inevitably to frustrations and throughout the world some sort of state medical service is inevitable in most countries, but I diminution of the standard of patient care. There was a great reluctance on the part of implore you in Austraha not to foUow the present pattern of the United Kingdom, and be hospital boards to inform the general public of the problems, and there is no doubt that the warned by our experiences. The future must devotion of the nursing and medical staff trying be designed in full consultation with those to maintain the service, was exploited by the actively caring for the sick, to enable all politicians. In the original National Health members of a hospital staff to work in an Service of 1948, the three aspects of health care, atmosphere of mutual trust for the benefit of namely the hospital, the family doctor and the the individual patient, and for the advancement community public health services, were all of medical knowledge. separately controlled. In order to try and integrate these, and partly with the hope of The Old Smithy, saving money, the National Health Service was Little Milton, reorganized just two years ago. Oxford, 0X9 7PU. U.K.
WHITHER DERMATOLOGY ?* H. R. VlCKERSf
Oxford, U.K. Having been closely involved in medical and dermatological administration most of my professional life, and in view of the widespread medical and political unrest in many countries, this is an appropriate time to consider the place of dermatology in medicine in the future, and how dermatologists can best contribute to the advancement of medical knowledge. The way medicine is practised in each country is determined very largely by tradition, and by political climate, but the broad principles should be common to all countries. The basic aim of all doctors must be to help the patient and to try to prevent disease. To understand the present situation in the United Kingdom, it is necessary to bear in mind the way in which specialization in Great Britain evolved. Diseases of the skin was probably the first of the special branches of medicine. Although the majority of men attracted to the skin were physicians, there were notable exceptions such as Jonathan Hutchinson who, although appointed Assistant Surgeon to the London Hospital in 1859, was also on the staff of the Skin Hospital at Blackfriars. There was a great upsurge of building of Voluntary Hospitals in the United Kingdom in the second half of the 18th century. These hospitals were staffed on an honorary basis by general practitioners having an interest usually in medicine or surgery. Some of them became particularly skilled and gave up their general practice to specialize. It is in this stage that the United Kingdom differed from the rest of Europe, because the man who became a specialist usually no longer saw patients direct, but only those referred to him by another practitioner. This became the established pattern in Britain. Since the specialists were not paid for their hospital work, they had to make their living in * Based on a paper read at the Annual Meeting of the Australasian College of Dermatologists, Adelaide, May 1976. t Honorary Consulting Dermatologist, Oxford. Senior Lecturer in Medicine (Dermatology), Royal Postgraduate Medical School, Hamm.ersmith, London.
private practice. Because they saw only patients referred by other practitioners, inevitably this meant that the number of specialists in any area was determined not by the needs of the populace, but by the amount of private practice available. Skin disease was much more common among the poor than the wealthy, so specialists could only make a living in large towns. Before the introduction of the National Health Service in 1948, there was no whole time specialist in dermatology within 100 miles of London ; all the wealthy travelled to " Harley Street ". These men worked very hard since, in order to become known to the general practitioners who referred patients to them, they did enormous out-patient clinics, often at many different hospitals. It is very much to their credit that, in spite of this, many of them made valuable contributions to medical literature. There was therefore, in Great Britain, in the first half of this century, a very small number of dermatologists compared with the rest of Europe. In those countries, the patients themselves consulted the dermatologist without necessarily being referred by a practitioner; nor was it essential for the dermatologist to hold an appointment on a hospital staff. A photograph taken at the annual meeting of the British Association of Dermatologists, held in Oxford in 1928, shows only 36 present. Another consequence of private practice on the early development of dermatology, was the great difference between hospitals in the time when they first appointed a dermatologist as such. If any one of the staff was also interested in skin disease, and was thereby increasing his income, it was unlikely that a dermatologist as such would be appointed. University College Hospital, London, appointed a dermatologist. Sir William Jenner, in 1859 but Addenbrookes Hospital, Cambridge, did not create such a post until 1929. This was the hospital situation when I was appointed Honorary Second Dermatologist to the Royal Sheffield Infirmary and Hospital in 1939. I had to make a living in private practice,
118
H. R. ViCKERS
and picked up fees for doing a syphilis clinic ; the gonorrhoea being looked after by one of the junior surgeons. However, I had joined the R.N.V.R. as a medical student in 1931, and was mobilized on the outbreak of war. It says a great deal for the faith of our elders, that long before the war was drawing to an end and when the outlook for our survival was not too rosy, they were actively engaged in considering the problem of medicine after the war, within the concept of a National Health Service financed by the state. It was reahzed that the old system of hospitals being dependent on raising private money could not survive. At that time, I, as a young consultant, attended several meetings, held usually at St. John's Hospital, to consider the future pattern of dermatology in Great Britain. Most of the discussion was centred on the training of dermatologists and whether or not a specialist dermatological qualification should be introduced—granted at the end of a statutory training period on the result of an examination. Already the ophthalmologists and oto-rhinolaryngologists had introduced a Diploma in their respective subjects. We had several very full meetings in which the views of the young were sought, since any changes would have a much greater effect on their future. It was felt very strongly that since dermatology is a branch of general medicine and that in dealing with skin disease inevitably one encounters internal disease manifesting itself in the skin, it was important for any dermatologist to be trained initially in general medicine. It was therefore decided that a dermatologist should first of all obtain the M.R.C.P. and then be trained in dermatology. It is of interest that this is now the pattern in all the newer branches of specialized medicine—neurology, nephrology, gastro-enterology, cardiology etc. It was also felt that there was a real risk of downgrading our branch if we established a separate dermatological qualification. This is still the situation in Great Britain, i.e., there is no higher qualification for dermatologists apart from the M.R.C.P. in which skin questions may be asked, and dermatologists serve for a period as specialist examiners. A diploma has been instituted by the University of London, the object of which is to enable those who have completed the year's intensive course at the Institute of Dermatology (St. John's) and who come very largely from developing countries, to have some tangible proof of having reached a standard of proficiency before returning home.
This qualification, in the absence of the M.R.C.P., is not regarded in Britain as entitling the holder to apply for a consultant post. More recently, with the forthcoming removal of medical barriers between countries of the European Economic Community, the problems of recognition of specialist status are very real. In the past, one was recognized as being a consultant in any branch of medicine in Great Britain by obtaining a consultant post in open competition. This obviously is of no value to a young man who has done all the necessary training for a consultant post in Britain, but who then decides to work in another country in Europe. Without some proof of his ability, this could lead to difficulties and again, the introduction of a specialist examination was discussed. I was opposed to this and the reasons for taking this view are simple. In Great Britain now, the National Health Service is a monopoly employer, and it is almost impossible to make a living outside the National Health Service. If a young man spent at least four years training, say in dermatology, then had to take an examination in order to be regarded as a specialist, and failed, it would be impossible for him to make a living in dermatology. He then would have difficulty in getting into any other branch of medicine, as a trainee, because of his age. The situation now is that all trainee posts in all branches of medicine are inspected by teams appointed by the relevant Royal Colleges, and anybody who undergoes training in such an accredited post, having passed the M.R.C.P. provided he has satisfactory reports from his teachers, will be accredited as a specialist. In the United Kingdom, he will still have to ap}:)ly for consultant posts in open competition, but he will be able to work in Europe and go into private practice there, if he wishes. The evolution of the speciahst branches in the United Kingdom is relevant to our future. A dermatologist should be essentially a physician with a special interest in the skin. T'his view was ingrained in me by three dermatologists, all of whom had a great infiuence on me in my early years. Rupert Hallam, my original teacher, John Ingram who then worked in Leeds, and Geoffrey Dowling whom I had the very good fortune to get to know when I was working in London in 1939. During my 39 years in dermatology I have seen nothing which has made me wish to change this view, and having observed the development of dermatology and other branches of medicine in other countries, in separate isolated units or
WHITHER DERMATOLOGY ?
institutes, my original view has been confirmed. Dermatologists must work closely integrated in general hospitals. So many of the patients we see also have complicated internal problems. Many of the fascinating manifestations of disease in the skin I see are referred by other specialist members of the staff. This close link is impossible to establish in separate institutes or special hospitals. It is over lunch or in the common room of a hospital that important contacts are made. I also feel very strongly that we should make every effort to take an active part in the Grand Rounds and hospital chnical meetings. It is through this type of discussion that new advances, often relevant to our own problems, are aired, long before they appear in the medical journals. This leads to the next point, that is, the importance of interesting the basic scientists in our problems. Fortunately, this has recently become much easier with the introduction of new techniques enabling the skin to be used as a valuable investigative model. It is much better to cooperate with an active basic sciences department, than having one's own basic scientist, e.g., biochemist or immunologist, working isolated from his fellows in a dermatological department. Such links have been established in Oxford and they are now bearing fruit. There is active cooperation with the microcirculation experts, the collagen experts, the immunologists, the M.R.C. leprosy research centre at Mill HiU, the biochemists, and so on. With regard to advances peculiar to our own branch, we have to encourage research in histopathology, photodermatoses, genodermatoses etc., but these specialized units should be attached to selected dermatological departments, and each department should not try to have its own photokinetic king or geno dermatologist. Such collaboration is inevitably time consuming, and may be difficult to fit in with very heavy clinical commitments. One of the advantages which many of us welcomed, arising from the National Health Service in 1948, was that we were no longer entirely dependant on private practice for making a living. The National Health Service salary not only provided our bread and butter, but enabled us to find time to take a more active part in hospital activities. Another of the benefits of the National Health Service was the establishment of departments in hospitals where there was a dermatological need. It has been possible to recommend the establishment of new viable posts throughout the country, and gradually
119
to restructure existing ones to abolish the old problem of peripatetic dermatologists who had no real allegiance to any one hospital. In Great Britain with the present financial stringency, with the exception of finding a very wealthy donor, the only way we can estabhsh University Departments of Dermatology in future, is for the dermatologists to demonstrate to both their fellow clinicians, and basic medical scientists, that dermatology has an important role to play in the advancement of medical knowledge. To establish a clinical chair in a University such as Oxford now requires about half a million pounds, and one has to have a cast-iron case in order to extract this sort of money from a tight university grant, in competition with all the other worthy claimants. My view is that dermatologists should remain actively integrated with general medicine and basic science departments, and there is still great relevance in the opening of the preface of the Fifth Edition of Frasmus Wilson's book, " Diseases of the Skin", published in 1863, " Cutaneous medicine is an important branch of general medicine : it embraces every form of pathological change which takes place in the external surface tissues of the body. It demands, for a thorough comprehension, all that appertains to the philosophy of general medicine, as well as the particular knowledge which belongs to the dermal textures. It presents to our notice in the double sense of a disturbance of the general organism of the body, and as a disturbance of the special organism of the skin. It includes all that concerns the health of the individual: in its special or local character it comprehends, in an equal degree, all that belongs to the organism of the part:—its vessels with their blood ; its nerves with their governing principles; its glandular apparatus with their secretory functions ; and its various component tissues ". This is therefore the way ahead for our branch. Although working in isolated units has many attractions, the ultimate result would be to stultify the expansion of dermatology and eventually lead to dermatologists reverting to " pimple doctors ". To deal briefiy with an aspect of British medicine which is probably of concern to other countries at this time of political unrest, the National Health Service. Most young consultants welcomed the introduction of the National Health Seivice in 1948, for the reasons already mentioned, and the very real advantage of being able to treat the patient without having to take the cost of treatment into consideration.
120
H. R. ViCKERS
By the system of whole-time or part-time Unfortunately this coincided Math infiation, contracts, the consultants were able to do a and from every point of view has, in my opinion, varyihg amount of private practice, being paid been disastrous. There has been a mushroom for their hospital work proportionately to the growth of all types of consultative committees, time they spent each week in the hospital. This and not only are these enormously wasteful of worked very well in the first few years, but valuable professional time, it is now almost with the new advances in treatment and impossible to get any decision on a problem. diagnostic techniques, costs escalated and Paper is circulated in vast quantities ; the old successive Governments were unable, or days when one could drop into the hospital unwilling, to finance the service adequately. administrator's office and discuss difficulties Apart from difficulties arising from delays in with him have gone since he is always " in either buying modern, or replacing worn out committee ". The service is foundering under equipment, the salary scales of all grades of the dead weight of consultative committees staff failed to keep up with the increase in the divorced from executive control. cost of living. There was difficulty in recruiting With the altering social and political climate nurses, secretaries, hospital porters etc. and all this leads inevitably to frustrations and throughout the world some sort of state medical service is inevitable in most countries, but I diminution of the standard of patient care. There was a great reluctance on the part of implore you in Austraha not to foUow the present pattern of the United Kingdom, and be hospital boards to inform the general public of the problems, and there is no doubt that the warned by our experiences. The future must devotion of the nursing and medical staff trying be designed in full consultation with those to maintain the service, was exploited by the actively caring for the sick, to enable all politicians. In the original National Health members of a hospital staff to work in an Service of 1948, the three aspects of health care, atmosphere of mutual trust for the benefit of namely the hospital, the family doctor and the the individual patient, and for the advancement community public health services, were all of medical knowledge. separately controlled. In order to try and integrate these, and partly with the hope of The Old Smithy, saving money, the National Health Service was Little Milton, reorganized just two years ago. Oxford, 0X9 7PU. U.K.
