When Thomas B. Fitzpatrick first studied skin at Harvard. Medical School over 40 years ago, he felt that dermatology, the science of skin, was in a primitive and ...
Festschrift Thomas B. Fitzpatrick —A powerful Difference
When Thomas B. Fitzpatrick first studied skin at Harvard Medical School over 40 years ago, he felt that dermatology, the science of skin, was in a primitive and unsophisticated state compared with other disciplines in medicine. He felt that the connections to basic science were limited, the treatments were largely irrational, the disease classifications were poorly founded, and there was a suggestion of something ‘‘strange’’ about a specialty in which morbidity so outweighed mortality and which aligned itself proudly with veneral disease. These observations could have been made by any bright, mature, World War II medical student who grasped (he perspective and potential of advancing biochemistry and cell biology. What was different about Fitzpatrick was that he decided that the state of cutaneous medicine was not a hopeless disadvantage to be avoided or to be reluctantly accepted in return for the ease, income, and chance for impact that dermatology provided. He saw it as a challenge, and he wanted to make a difference. He decided that he wanted to infuse dermatology with science, enthusiasm, respect, and logic without losing sight of clincial focus, morphology, and patient care. He felt that dermatology could stand as a sturdy separate speciality because skin is such a unique and fascinating organ in health and disease; at the same time, he felt that the approach to patients and attitudes in dermatology could integrate the qualities most admired in internal medicine. Today we celebrate Fitzpatrick’s extraordinary successes in making a powerful difference. In the next four decades Fitzpatrick was to train 119 dermatologists (44 of whom became full-time academicians, 13 of whom remained at Harvard Medical School, and 10 of whom became chiefs of dermatology sections or departments), organize and edit a major dermatology textbook, contribute pivotal basic research concepts, teach thousands of medical students to be curious and enthusiastic about skin, and mold several rational clinical classifications of disease, including criteria for early diagnosis of melanoma. While doing all of this, he always used clinical practice as battlefield, teaching site, ultimate challenge, and source of questions. Dermatology can be gratified that Fitzpatrick saw the specialty’s weaknesses as untrodden ground and as the object of his complete, jnembarrassed, unqualified, and untiring career committment. HISTORY Thomas Bernard Fitzpatrick was born on December 19, 1919 a Madison, Wisconsin. After undergraduate studies at the
University of Wisconsin, he obtained an M.D), at Harvard Medical School and a Ph.D. at the University of Minnesota. His internship at Boston City Hospital left a permanent imprint f the thoroughness, pride, and work ethic associated with internal medicine. A 2-year assignment in the Army, where he jmed forces with A. B. Lerner, and a fellowship at Oxford niversity provided training and expertise in biochemistry. The Mayo Clinic and the University of Michigan, traditionally strong dermatology units, provided the environment to pour energy into the study of normal and abnormal skin and to learn pile organ well enough to teach about it and teach well. The single, smartest move of Fitzpatrick’s professional, social, and personal life was his alignment with Beatrice Devaney in 344. Bea became his wife, lover, best friend, sustainer, and social grace. She has quitely built an international reputation a dermatology based on solidity, charm, intelligence, understanding, and warmth. Their union has produced 5 children, who now as young adults pay their dad the highest, complement—they are his close friends. Tim, Terry, John, Scott, and Brian are bright, intelligent, artistic, handsome people with Rolls-Royce engines and great personal force. At the age of 32, Fitzpatrick was named Professor and Head of the Division of Dermatology at the University of Oregon, and at the age of 39, he was named Edward Wigglesworth Professor and Chairman of the Department of Dermatology at Harvard Medical School and Chief of Dermatology at Massachusetts General Hospital and Harvard Medical School. He presently holds these positions after more than 23 years. RESEARCH CONTRIBUTIONS: IDENTIFYING, ISOLATING, AND PROMOTING In 1949, nine papers by the 29-year-old Fitzpatrick and his close friend Aaron Lerner on the biochemistry of melanin pigmentation marked the begining of a most productive research venture in dermatology. Fitzpatrick seems particularly skilled at synthesizing information and has an instinct for identifying the potentially important, isolating the interesting components, and describing concepts in appealing, almost simple terms that are widely understood and embraced. He always works with others. His motivational, stimulating, and question-asking skills are so good that it’s often not possible (even for him and his collaborators) to identify where and when in their interpersonal and intellectual exchanges ideas were formed and answers were demonstrated. He was and is certainly unafraid of large volumes of sheer hard work in developing a research project. His intellect, energy, 3s
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collaboration, and creativity have thus generated a large volume of important, ideas and information for dermatology and biology in both basic and clinical aspects. Fitzpatrick’s research contributions are known to the investigative dermatology community mostly because they have been very important, but also because he presents them to his colleagues well and often. We list them here mostly for the record and to demonstrate the length and breadth of his work spanning more than three decades. Reference numbers refer to the Curriculum Vitae published in this volume. 1. The identification of three essential elements in the basic processes of melanin pigmentation: (a) The first demonstration of tyrosinase in humans [6]. Tyrosinase had been shown in animals and insects, but not in humans. The fact that there were differences in the level of concentration of tyrosinase in benign and malignant melanocytes provided stimulus for pursuit of a rational chemotherapy of metastatic melanoma based on a selective localization of cytotoxic radioactive chemicals in malignant melanocytes, (b) The isolation and characterization of the metabolic unit of melanin pigmentation, which he called the melanosome, with his close friend and -Japanese collaborator Professor Makoto Seiji [48, 56, 57]. (c) The development of the concept of the epidermal melanin unit, with the British anatomist A. S. Breathnach [58]. This concept, applied to animals and humans, recognizes a partnership of melanocytes and keratinocytes in the process of pigmentation and advanced a view of the epidermal melanin unit as a functional and structural unit analogous to the nephron. 2. The development of clinical critiera for the early detection of cutaneous malignant melanoma with W. H. Clark and M. C. Mihm [61,106,183]. This work, which Fitzpatrick considers his most important contribution, leads to life-saving by medicine’s most impressive maneuver—prevention. 3. The application of the scientific method to the development of topical sunscreens, with his long-time collaborator M. A. Pathak [83]. A pivotal paper in the New England Journal of Medicine promoted a rational approach to the development of topical sun protection agents. These agents and their promotion, through education of industry and the consumer, have been a most important factor in the reduction of ultraviolet-induced skin cancers in humans. 4. The identification and delineation of white-leaf-shaped macules as the earliest sign of tuberous sclerosis [79]. This is used throughout the world for the early detection of this autosomal-dominant neurocutaneous disorder that can be associated with severe central nervous system abnormalities. Early detection allows genetic counseling of patients before further complications occur. 5. The demonstration of beta-carotene as a photoprotective agent in erythropoetic protoporphyria, with M. M. Roth and M. A. Pathak [87]. This was the first application of an in vivo photoprotective biological principle to the treatment of human disease. 6. The characterization of giant pigment granules (maeromelanosomes) in the cutaneous pigmented macules of neurofibromatosis, with K. Jirnbow and G. Szabo [104]. Although these giant pigment granules are also present in 4s
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other disorders, they are ultrastructural characteristics of the cafe-au-lait macules of neurofibromatosis. A significant quantiative difference in the number of these particles in the skin of patients with neurofibromatosis may have diagnostic significance in detecting this disorder early, even prenatally. 7. The role of sunlight in the etiology of melanoma, with A. Sober [159]. While it is not proved that UV-B is the etiologic waveband for the development of melanoma in humans, most researchrs now agree that sunlight plays a role in the development of melanoma. 8. The development of the concept of photochemotherapy, with J. A. Parrish [124,131,143,144,150,152,157, 175]. Fitzpatrick had shown in 1955 [27] that oral administration of psoralens could result in a striking hyperpigmentation relative to erythema, and he has been active in improving and promoting psoralen therapy of vitiligo since the late 1950s. He and Pathak invested 30 years in the study of the photochemistry and biochemistry of psoralens. The quantitative UV-A photobiology studies of Parrish in the early 1970s facilitated the introduction of oral psoralen photochemotherapy of psoriasis and subsequently of several other disorders. The treatment, called PLIVA, was initially confirmed and improved by Wolff and subsequently by many others around the world. LEADERSHIP IN DERMATOLOGY Thomas B. Fitzpatrick belongs to over 20 national and international honorary medical societies and has been President of the Society for Investigative Dermatology, the Dermatology Foundation (which he organized with Dr. Irvin Blank), and the International Pigment Cell Society, and in 1984 he will be President of the Association of Professors of Dermatology. He has also been consultant to the National Institutes of Health, the Food and Drug Administration, the National Academy of Sciences, and other agencies, and he has served on many important committees that, set research policies and priorities. Fitzpatrick has not only been a major force in the politics and policies of American dermatology, but he has also been an unembarrassed ambassador for dermatology all over the world. He travels and teaches widely. For example, he has gone to Japan to give lectures on numerous occasions, and over 20 Japanese academicians have studied in his research unit. Many of these are now leaders of dermatology in Japan. Fitzpatrick has also been on the editorial board of the New England Journal of Medicine for 7 years. He organized and is senior editor of a major dermatology textbook widely used not only in dermatology but also in other medical specialities. He is presently organizing the third edition of this most successful book, Dermatology in General Medicine. Despite all this national committment and international investment, his own department has grown to impressive size with a large; number of nationally known researchers and clinicians. When Fitzpatrick came to Harvard Medical School in 1959, there was only one full-time dermatologist at the Harvard teaching hospitals; now there are 14. In adition, the number of dermatology residents has increased from 3 to 14. Beth Israel Hospital, Children’s Hospital, the
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combined Brigham Hospitals, and the Sidney Farber Cancer Institute now each have divisions of dermatology with their own unit chiefs. Strong research units now exist in photobiology and photomedicine, keratin biochemistry, immunology, tumor cell biology, pigmentation biology, melanoma research, and percutaneous absorption. PATIENT CARE: IN THE TRENCHES Although overcommitted at all times, world famous, and surrounded by good researchers and teachers, Dr. Fitzpatrick never removes himself from the front lines as far as patient care is concerned. He consults and teaches in both inpatient and outpatient settings and has an unrestricted, busy, non-super-specialized practice of general dermatology. He delivers primary care one on one, facing cosmetic blemishes and very sick patients with serious systemic illness. He consults his well-worn textbooks in front of patients, examines scrapings from scaly toes, performs biopsies, learns and tries new treatments, asks questions, argues diagnoses, and looks at microscopic slides himself. He experiences the humiliation, frustration, anxiety, joy, and exhaustion known only to concerned physicians who accept the responsibility of uncu-shioned patient contact. He is a very competent clinician who is always happy to share his vast experience and also able to seek help from colleaques with specialized expertise. I have never seen him refuse to see any patient any time with any student or doctor. Patients are a major source of the yearning, learning, and earning of Fitzpatrick’s career. HOW DOES HE DO IT? (PERSONAL QUALITIES) A collection of well-known, admirable qualities of industry, commitment, concern, compassion, unselfishness, and sacrifice are common to those few who successfully combine teaching, research, and patient care. Fitzpatrick has been unusually successful because of his own brand of these necessary ingredients plus several other helpful characteristics. He has the curiosity and enthusiasm of a child and the tenacity and endurance of a love-struck teenager. TBF has a gambling instinct, which is useful to his career, because it is well channeled by this intelligence and his opportunistic good sense. He is totally unafraid to get involved and never gives up. His ambition for himself, his research, his program, and his specialty does not rest. His mind is turning over business when he is chatting; he is planning and strategizing when he is enjoying wine and a cigar at a banquet; he is scheming while swimming and dreaming while driving. Fitzpatrick can identify and motivate leaders and potential full-time academicians. One real measure of success of a teaching program and its leader is the number of committed full-time academicians it generates. Forty-four is a very impressive number when one realizes that many of these are world-class contributors in dermatology.
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Fitzpatrick can recognize the motivation formula in anyone. He is a survivor, and he nonverbally teaches others these same skills. With most but not all people in this program he wields the ideal carrot/stick ratio that keeps them working at or slightly beyond their own ideal high-output state. His recognition of this ‘‘kick/pat’’ ratio is evident in his characteristic compound sentences of praise and criticism used in private and public. The praise and boost that make people think they could really ‘‘make it big’’ are followed by a ‘‘zinger’’ that makes them angry enough to try. The most useful quality is an almost unbelievable and very appealing combination of resilience, pattern recognition, denial, ego strength, and optimism that guides TBF to eventually find his own form of positive interpretations of nearly all events. This ‘‘assimilation-positive conversion’’ skill goes well beyond a simple good nature and is quite a separate quality from Fitzpatrick’s sense of humor (some of my best, longest, and most visceral laughs have been with Fite). The first 10 to 15 times one observes this phenomena it may appear as a simple ‘‘polyanna,’’ face-saving, or protective stance. It becomes evident, however, that TBF actually experiences growth, learning, and positive reinforcement of his own world view from his skill of assuming, conceiving, or creating an interesting interpretation of apparently meaningless data, a helpful learning from apparent disasters, and a pony in every manure pile. This enviable trait seems to give Fitzpatrick the fuel for the endless energy he plows into his work and advancement. When his reports or accounts of events and situations have already been processed by this magic lens, the listener also creates fantasies of hope and magic and derives positive energy for work. This TBF translation process forces some of the people around him to assume the split-off roles of reality tester, pessimist, or storekeeper. Happily, and not by chance, TBF has always been surrounded by loyal persons eager to play these roles. They too seem to be touched by his lens, because they enjoy what might appear to be very frustrating roles and turn them into constructive channels. Dermatology has benefited enormously from this trait in one man, and we all could do with a dash of it. CONCLUSION As a medical student, Thomas B. Fitzpatrick decided to enter a specialty that he considered weak and backward. That speciality has been permanently improved by his decision. His successful career in the patient care, teaching, research, and politics of skin are so impressive that they extend well beyond dermatology, motivate us and those who will follow us, and cause us to dedicate this volume of work to him. John A. Parrish, M.D.
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