Commenlar¥ IIII I I III II

We bring to your attention a rather poignant piece of writing--the epilogue to the professional life of a distinguished colleague; a man with whom many of us are acquainted, either person- ally or through his published works. There are scores of politicized physicians willing to sell our freedom in the name of social justice, and hun- dreds of politicians anxious to sacrifice our inde- pendence on the altar of equality. Yet when the lives o f these zealots are examined, few are found to have acquired their fervor from the daily en- counter, decade after decade, in a one-on-one re- lationship with patients, and sacrificial fires gen- erally warm only those who actually light them.

Dr. Lyell's story illustrates what will surely happen to "marginal" specialties practiced by only a small percentage of the profession. Dr. Lyell 's dedication and good humor are known to all who have had the privilege of his acquaintance. His dedication to the ideal of full-time salaried service is manifest by his decision 20 years ago to go "full t ime" -a term used in Britain to describe those consultants who eschew entirely the concept of private practice, and give their time solely to "Heal th Service" patients.

In our youth, most of us have suffered the agonizing pangs of unrequited love, but happily we were rescued by our resilience. To have served so long and so faithfully a mistress so uncaring is devastating to contemplate. Wc love our profes- sion and our patients and we hope to serve them as long as our faculties will permit, and we hope to continue to do this in that degree of freedom which we believe is best for doctors and patients alike.

Peter J. Koblenzer, M.D. Caroline S. Koblenzer, M.D.

St. Christopher's Hospital Jbr Children 2600 North Lawrence St.

Philadelphia, PA 19133

Personal view*

It is intriguing to find yourself carried along the river of life, encountering in yourself signs of in- creasing age, and yet feeling as young as ever *Reprinted (with permission) from Br Med J 281:1065, 1980.

0190-9622]81/080247+02500.20/0 © 1981 Am Acad Dermatal

inside your aging carapace of flesh. The river has come far from the days when it was a little stream in meadows bright with flowers, through the tur- bulent waters of adolescence and the bleak rocky landscape of war, to calm reaches bordered by fields and woods. There seemed every prospect that it would continue quietly until, in due course, it merged with the uncharted sea that bounds all human life. Not an exciting prospect, perhaps, to the adventurous mind, but one well suited to my contemplative temperament. For some years, however, there have been indications that its gen- tle course would be rudely interrupted. A distant whisper o f sound became a murmur and then a roar. Now the falls have been passed and the water is rushing along over a rocky bed. It is a time to hold on grimly and hope.

The event portrayed is my retiral from the Health Service, aged 62, because of a conviction that I had come to a dead end: that the things for which I had planned and hoped and emptied my- self were not possible. After 18 years in charge of the department of dernaatology at Glasgow Royal Infirmary my sole testimonial from the health board was the letter from the assistant secretary, signed by someone else on his behalf. "Thank you for your recent letter in which you intimate your intention to retire early from your post, your last working day being 31 March 1980. May i take this opportunity to thank you for your service with this health board and wish you a happy retirement." If anything was needed to allay the doubts and anxi- eties through which I had passed it was that. When I came to Glasgow in 1962 I had been following my star. It showed me a vision of how dermatol- ogy could develop in the setting of a distinguished teaching hospital in a large city. My vision de- manded my whole allegiance so I eschewed pri- vate practice and went whole time.

There have been many stages on my road to disillusion. The most important has been the pro- gressive undermining of the power and influence of the teaching hospitals. It seems to me that this has been pursued as an act of policy. Deprived of their hoards of management and shorn of most of

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their endowment funds they are at the mercy of an administration that, to say the least, is less than enthusiastic about their value. I still do not under- stand the morality of diverting money that has been bequeathed by generous and grateful indi- viduals to the Glasgow Royal Infirmary for gen- eral use in the Health Service. Nor do 1 understand how new knowledge is to continue to flow if there are to be no centres of excellence. New knowledge has to be fought for continuously; it does not grow on trees. It is dynamic, ever changing, not a static commodi ty that can be parcelled out so that all get equal shares. It grows from foci of energy where thinking people gather together in a sufficient con- centration to achieve a critical mass, a concept quite contrary to the belief that centres of excel- lence are outmoded. The sterility of this fashion- able article of faith wilt become increasingly ap- parent as dying knowledge gives place to dogma, and dogma results in mindless, rigid, and stylised care of the sick.

During periods of fine financial weather der- matology receives a mod icum of support as well as much praise. But in the winter of our finances, when the fell wind of economy chaps and stings and the air is filled with cries of "pr ior i ty ," sup- port dwindles and the praise is seen to belong to' the mouth rather than the heart. Dermatology is still a Cinderella despite many protestations to the contrary by physician colleagues and others; de- spite the breadth of skills needed for its practice far exceeding those required by the internist, alias general physician. I say internist advisedly, be- cause it is still usual for physicians to classify themselves as general and other, the former seeing themselves as belonging to the " m a j o r " specialty of general medicine, while the latter, the others, constitute "mino r" specialties, such as dermatol- ogy. These are outdated terms. Physicians these days concentrate the bulk of their activities on one internal organ or system. They also require a cer- tain skill in medical first aid so that the acutely ill patient shall not die before he can reach the care of the appropriate specialist. Few doctors are gen- eralists in any true sense. Indeed, few of any who may claim this title care to exercise their general knowledge of dermatology. "You know, old boy, I never could understand these damned rashes,"

says the doctor who needs your help. Maybe, but you, as a dermatologist, need to have a working knowledge of his special subject and of the special subjects of his colleagues, and of aspects of sur- gery, of gynaecology, venereology, radiotherapy, oral medicine, therapeutics (with special reference to adverse reactions to drugs), and psychiatry; you need to be able to interpret skin biopsies and to discuss them with the pathologist; you need a special knowledge of the environment and its hazards that will bring you into contact with climatology, botany, entomology, and the chemis- try of industrial processes and products. Which do you think is a generalist?

And so I have come to the unhappy conclusion that, since the Health Service seems unconcerned about the health of dermatology, we must part. I have retired from the Health Service, but not from dermatology. I intend to do many things, some of them dermatological, that there has not been time for. The comfort of being able to work with a purpose, untrammelled by the frustrating adhesive tape of regulations, inhibitions, irrelevancies, and shortages incident to the Service, is immense. My life up to now has not been wasted. An exper iment has been conducted that has given a clear-cut re- sult. I have tried to build an excellent depar tment of dermatology within the context of the Health Service. The world has been interested but the Health Service has not.

You young men and women who have an urge to advance dermatology, do not give your whole life to the Health Service because the Health Ser- vice will let you down. Give yourselves to der- matology and your patients and aim at excel l ing at private practice. Plough back the money and the influence you obtain into dermatology. By doing so, in co-operation with your colleagues, you will be able to advance dermatology independently of the Health Service and of priorities that would be decided for you by committees. Bless you, you fill me with hope for the future of the subject that I love.

Alan Lyell Retired consultant dermatologist

Skelmorlie, Ayrshire