The Dermatologist as an Individual—An Appraisal of Cultural Trends

THE DERMATOLOGIST AS AN INDIVIDUAL—AN APPRAISAL OF CULTURAL TRENDS MAXiMILIAN E. OBERMAYER, M.D. Los Angeles, California

Chairmen's addresses often comply with certain traditions, one of which is that they be philosophic in nature. In our field one might, for instance, talk about "The Dermatology of Yesterday, Today, and Tomorrow." Such a choice is spurned by those who feel their audience would rather listen to a creditable report of research. I think I can appreciate the motivations for the latter choice and I find no fault with it. Yet the thought occurs that a president of a national society could be expected to offer something of broader nature than a topic that his younger colleagues may be able to present as well—or even better—than he. Usually this office has been conferred on him in view of his many active years in furthering the aims of the medical specialty he serves. Presumably mellowed by time and experience, he should have achieved a perspective yet to be realized by the younger members of his audience, and therefore be able to see much that they, with their noses to the grindstone, do not. If such perception gives rise to thoughts worth pondering, it would seem a duty to pass them on. I hope you will bear with me, therefore, if I talk to you—the torch-bearers of

research in dermatology—about a subject that may seem only indirectly con-

nected with your investigative or teaching activities. Perhaps, when I am through, some of you may agree that the connection is not as tenuous as it may seem at the outset. My first premise is this: In narrowing one's interests to the means of earning a living—even if that means be a professional and scientific occupation—a man denies himself a broader heritage of knowledge, culture, and wisdom. Today's young dermatologists, although superbly schooled in their specialty and their efforts crowned by the passing of the examination of the American Board, too often plunge themselves into activities of such exclusive nature as to limit—or even prevent—their well-rounded development as individuals. Their concentration of interests divides them, roughly speaking, into two groups. One group—the smaller by far—soon confine their pursuits to materialistic endeavors. While they may be efficient practitioners of the skills acquired during their years of training, all thought is directed toward the building-up of a large practice, and to this end their entire social and cultural life becomes geared. Little need be said about them and their state of intellectual poverty. The men who comprise the larger group—those to whom I address myself today since you would not be here if you belonged in the other category—do not lose sight of academic and scientific goals in their practice of dermatology, as Read before the Eighteenth Annual Meeting of The Society for Investigative Dermatology, Inc., New York, N. Y., June 1, 1957. 241

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do the others. But in pursuit of these goals with such all-absorbing zeal, they may crowd out of their lives those interests and activities that would broaden their cultural outlook. "Is that so deplorable?" some of you may say. "Is not single-mindedness of purpose essential to the solving of intricate problems, and is not the fruit of research like the solution of a jigsaw puzzle? The small pieces of the puzzle, like the individual research projects—no matter how narrow— must be perfect if eventually, after many trials and errors, they are to fit to make a whole." There is truth in that comparison, at least to some extent. But what is more important is this: The significance—the fitness—of even the smallest piece of research depends on the judgment of the investigator. Without good judgment experimental plans and conclusions often are erroneous. We are all only too well acquainted with ludicrous examples—the reports that clutter up the pages of many medical journals. And this brings me to my second premise. Good judgment is not born of tech-

nical knowledge and intelligence alone. Webster defines judgment as, "The operation of the mind, involving comparison and discrimination, by which knowledge of values and relations is mentally formulated." But this power is possessed only by the mind that has been developed by the challenge of problems of wide variety, scope, and depth. One-sided education confines the range of such challenge and therefore hampers the development of judgment.

Moreover, narrowness of experience obviates imaginative and creative attitudes. The ability to inspire is rarely possessed by the teacher with a narrow cultural and educational background, a consideration of significance since most of

us are teachers as well as investigators. The teacher with a restricted background, even though expert in his particular field, is often an eccentric individual who leaves an indelible mark on his students by his peculiar ways as well as by his knowledge of the special subject on which he is considered "hepped." Not a

complimentary concept, you will agree. "But how," you may ask, "do these views on educational background apply to us? Aren't we dermatologists well educated after all these seemingly interminable years of going to school?" Yes, we are well educated—in a sense, and in another sense many of us are not. The purpose of education, Sir Richard Livingstone pointed out, is not merely

to prepare us by training in a specific field to earn our bread. Our education should give us some understanding of the universe and of man, and it should help us to become fully developed, mature human beings. The acquisition of standards of value and judgment applicable to all human spheres and activities, and the power to discern what is truly "first rate," or of the highest quality, are among the objects of a good education. Are these objects being realized today? I am afraid they are not. The trend is to shun any endeavor not directly aimed at the specialized goal. The old saw about travel being broadening is all too true. We are inclined to become provincial in our attitudes if we restrict our knowledge and activities to the home field, whether it be a geographic or a mental realm. This educational and cultural trend is not peculiar to our own country, however. You may recognize it more clearly when viewed from a distance: Since the

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end of the First World War a cultural corroding process has been going on in

some European countries. The great majority of their citizens, however, have failed to recognize this insidious cultural and educational decadence, and unconsciously—even if understandably—still identify themselves with the glorious pasts of their schools. It is no wonder, then, that a storm of protest was raised when the American Medical Association started to look with a jaundiced eye at the more recent products of some European medical schools. The angry rebuttal was the Biblical simile of the mote and the beam.

Naturally we reject the beam, but searching the eye of many a young physician of our specialty, I admit to spots considerably larger than the proverbial particle of dust. Although he is a likeable fellow and a good solid citizen, he is not a well-educated man in the sense of Sir Richard Livingstone. His cultural deficiencies are revealed in many spheres, a few of which I should like to discuss. They concern the use of language, knowledge of history, inner resources, and critical judgment. Many of you who are members of editorial boards or have had to screen examination papers must have been appalled by the bad spelling and lack of clear expression that characterizes too much of the medical writing today. Many socalled manuscripts are nothing more than a collection of unclear ideas whose com-

mitment to paper has been unhampered by grammar, organization, or thought. The use of our own dermatologic terms is often pitiful: Since "the little Latin and less Greek" of the older generation has reached the vanishing point in the curricula of the present generation, the young physician—with little or no feeling for even his mother tongue—has callous disregard for terminologic accuracy; he is apt to shrug his shoulders instead of blushing when it is pointed out that he spelled pruritus with an "itIs"; or a young dermatologist may even get his dander up when rebuked for saying erythrodermia psoriaticum. Knowledge of the history of medicine among our younger colleagues is practically nonexistent. Several years ago a few historical questions that were most pertinent to the field were included in the written examination of the American Board of Dermatology. When the results were taffied it became apparent that the quality of the responses was so poor that the questions had to be thrown out. As scientists you have learned to appreciate the virtue of curiosity. The young physician who lacks curiosity regarding the accomplishments of the past cuts himself off from the wisdom of those who constructed the edifice upon which we build but one more story by our current efforts. He denies himself, also, the sense of cultural and scientific continuity that can enrich his personal satisfaction in his work. To be more critical, a deliberate disregard for the historical progress of the profession one has chosen as a life work would seem a deplorable intellectual fault. Knowledge of history has practical values, too: Awareness of what has been done by one's predecessors helps to avoid embarking with misdirected enthusiasm on problems of research conceived and resolved generations ago. By inner resources I mean the treasure of things within himself to which a man resorts when his day's work is over. Medicine is one of the learned professions, yet many of us have within ourselves a meager range of learning. Time was

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that the physician was regarded as a cultured, erudite individual. His knowledge of the nature, the interests, and the problems of man elevated him in the eyes

of the community so that his counsel was valued in many matters other than those of his calling. His interests were wide, and included the esthetic as well as the strictly scientific. His inner resources were manifold. To such a man, in his hours of leisure, his interest in history, literature, music and the other arts, and in other branches of science provided inspiring and gratifying means of relaxation and renewal of spirit. In his social encounters he did not need to fall back on discussions of personalities or to talk shop—often with an eye to self-aggrandizement—nor rely on trivial games and the like to pass the time. But today's specialized education does not prepare the individual to LIVE—only to WORK.

Not many men are blessed with artistic talents as were some of our Great in Dermatology: Sabouraud and Kreibich as sculptors, lJnna and Lewandovsky as cellists, to name only a few. Not many have the wide horizons of a James C. White, a Louis A. Duhring, or a George Henry Fox. But it is with the exercise to critical judgment that I am most concerned. The art of medical practice consists chiefly in a judgment regarding the appropriateness of concepts in etiology, diagnosis, treatment and prognosis. How can there be good medical judgment when a person is incapable of independent judgment in other spheres? We are in this respect at a particular disadvantage, because in our democratic society there are tremendous pressures toward uncritical conformity. The levelling tendency is always downward, for egalitarianism denotes the lowest common denominator. Too few dare the rigors of independent thought—whatever the subject—and many who so venture have to pay a high price for their courage. The result is that our average young physician is not an interesting person. He is self-complacent, comfort-loving, and unenterprising, and this smug attitude is sometimes coupled with colossal ignorance as well as lack of curiosity about anything not pertaining to the immediate and only goal, i.e., the successful passing of the examination of the American Board of his specialty. His understanding of human nature is often superficial; he does not realize that "normal" covers a wide range in sexual, social, and moral spheres. This has become apparent to me in connection with the pursuit of my special interest in psychocutaneous medicine. There is either enthusiastic acceptance or emotionally-tinged rejection of the subject, but attempts at critical evaluation are scarce. The paucity of knowledge outside the immediate field of interest is exemplified in the hesitancy on the part of some young dermatologists to express an opinion

on a question involving general medicine in round table discussions with his colleagues in other specialities. Particularly evident is a disinclination to independent thought in evaluating cases. Worse stifi is the increasing disregard or even disrespect for clinical work and clinical investigation. Naturally, we are all fully aware that progress in clinical medicine has become inseparable from laboratory work. But the belief seems widespread that research, to have any real

value, dignity, or validity, must be done in biochemistry, biophysics, histo-

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chemistry or on laboratory animals—in other words on anything but the patient! Could it be that this shying away from working with the fellow human being is an indication of basic insecurity on the part of the investigator, of his subconscious realization that with his scant capability for judgment he had better sit behind the Erlenmeyer flask whose contents have no personality and fewer variables? Whatever the reason, the trend is dangerous, for if it continues, the dermatolo-

gist may find himself one day merely an artisan who utilizes the facts and pseudofacts handed down to him from the laboratory as his tools, to be adapted —with scant discrimination—to the needs of his patient. And Dermatology, the Study of the Skin, will have lost its identity as a branch of medical science by having been parcelled out to biochemists, microbiologists, and physicists. How can these deficiencies be remedied? To answer this question is not easy because, as I have pointed out, the process of cultural corrosion is widespread in the western world. There are even some essayists who think that we are passing through an inevitable terminal phase, that our civilization marks the end of

a culture and the end of a world phase in the Spenglerian sense. I am not so pessimistic. Long-range programs have been or are in process of being instituted which are designed to combat these deficiencies. The most important of these is real, functional integration of the medical school with the humanitarian aspects of the university as well as with its scientific areas, a kind of diagonal program with both liberal arts and basic science courses from the third through the sixth

years of the total eight required. True, a knowledge of the humanities is not identical with culture. But it is a means of enlarging the life experience; and if the humanities are taught inspiringly, the young man is likely to pursue their study further in his leisure. It is the carry-over into his later professional life that will determine whether he has become an educated man. More immediately, improvement could be obtained by greater discrimination

in the choice of graduate teachers in Dermatology. Eligibility should not be influenced by number of publications or by wizardry of mechanical invention; nor should the abstract scientist, whose eminence—however remarkable—is limited to a small segment of our field, be selected for such a post. Since training in judgment is best obtained by precept and example, the man who is responsible for the training of dermatologists should be, primarily, one whose cultural and

educational background has been such as to permit development of sound judgment. He should have a full knowledge of human nature in all its ramifications. His ability to discriminate values and to understand the fitness of things should be well established. These qualities will make him, also, a superior clinician, and clinicians are needed if the specialty is to survive. Under the guidance of such a man the contributions of biochemists, microbiologists, and physicists will become even more significant. The goal of education in our field should encompass not only expert scientific training, but also the cultural development of the man. A dermatologist with a good cultural background and depth of inner resources will not lose himself in the exclusive pursuit of abstract science; nor will he easily fall victim to shallow materialistic aims. He will not only better serve the cause of Dermatology but

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also retain the respect and confidence of the public. Most of all, our new derma-

tologist will be a happier man because he will have been able to acquire a philosophy of life with standards of value and judgment that apply to all spheres and activities of man. BIBLIOGRAPHY ELKIN, D. C.: A case for the study of the humanities in the making of a doctor. Ann. Surg. 136: 337, 1952.

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