After graduating as a doctor in Groningen in December 1975, I started my training as a dermatologist on January 1, 1976, also in Groningen. Back then, the training lasted 4 years, so on December 31, 1979 I left the clinic with a written certificate from the professor-instructor Prof. Dr. A.H. Klokke, that I was found suitable to practice dermatology independently. I have already written down my memories of this period in the chapter 'Memories of a former assistant' in the jubilee book Vallen en opstaan, which was published in 2013 on the occasion of 100 years of the Chair of Dermatology at the University of Groningen (1913-2013), edited by Marcel F. Jonkman (then professor of dermatology) and Peter Verhoef, the owner of Erasmus Publishing, the publisher of the book. The chapter is shown in full below, with a few extra added photographs. If you have a moment: read it (I have translated it for you in English), there is quite a lot to laugh about!

PLEASE BE ADVISED THAT THIS TEXT WAS WRITTEN IN 2012

Memories of a former assistant in training to become a dermatologist

Dermatology training in the 1970’s: those good old days?

Anton C. de Groot

promise that I could train with him after graduating. He did not take my kind request to put this on paper as an insult and I was allowed to go straight to his secretary. Now I just had to complete the internships and pass my exams...

During one of my visits to the clinic I was introduced to Dr. Andrew Herxheimer (no, not the namesake of the Jarisch-Herxheimer reaction, that was his uncle), a pharmacologist and dermatologist from London. The clinic arranged for me to do a three-month internship (!) at the London Hospital Medical College. I would learn how to write articles (success, thank you very much, Andrew) and do a literature review on the side effects of oral antihistamines. Not much came of the latter, but what a wonderful time it was! There were parties everywhere and I had a habit of ringing the doorbell of houses where a party was going on with a gallon of beer in my arms. I could easily afford that, because I received the salary of 'chief assistant physician' and all expenses were paid. Such a giant can of more than 4.5 liters was almost always enough reason to swing open the party door: 'welcome, Tony!' 

During my farewell, Dr. Herxheimer said: 'Tony has become the most notorious gatecrasher of the East-End of London in the last three months'. A gatecrasher, you will understand, is someone who comes to parties uninvited. In December 1975 I returned to the Netherlands, a stone (8 kilograms) heavier due to all the beer (lukewarm, that is) and the curries, which you could also eat late at night in one of the hospital dining rooms. I will always be grateful to Prof. Klokke for making this fantastic (and also educational) time possible for me. Immediately afterwards, on December 16, 1975, I graduated and two weeks later I would start training to become a dermatologist: the adventure was about to begin!

Memories of an assistant

The clinic

And so on January 1, 1976, at the age of 24, I became the youngest clerk in the dermatological clinic of the University Hospital Groningen. At the time, it was a sturdy apartment building with a ground floor, three floors and a basement, somewhere in the corner between the Oostersingel and the Antonius Deusinglaan in the city of Groningen. The basement was particularly important, because we could play table tennis there during lunch time! The ground harbored the outpatient clinics (two general and the venereal disease outpatient clinic), the reception, the administration and the waiting room for patients, the room of the head of the outpatient clinic (but it may also have been on the first floor), the blood lab, treatment rooms (radiation, surgery), the allergy department, and also the mycology laboratory, I think.

On the first floor were the staff members' rooms, the histology and immunology laboratory, the professor's secretariat, the library and the photography department. It is hard to believe, but the library was about ten times larger than the windowless room where the current library (a cupboard with books) is stationed. And then the chef de policlinique also resides in that cage! Poor Dr. Pieter Van Voorst Vader, how sad he must have been to see his biotope shrinking dramatically over the course of 30 years.

The second and third floors were the nursing wards. The men's rooms and class rooms were on the second floor, and the women's and children's departments were on the third floor. The number of beds was large (about 40, and another 40 for children), because at that time much more dermatological treatment was provided with inpatients than today. The rooms of the department secretary and of sister Venema, the head nurse, were also on the second floor.

The assistants (trainees in dermatology)

On January 1, 1976, there were five assistants training to become dermatologists: Bertus Hartman (until  April 1, 1976), Bouwine Wakkers-Garritsen (until April 1, 1976), Toon Baar (until June 1, 1977), Vincent Gooskens (until June 1, 1977), and Hylke Terpstra (until mid-1978). Bertus Hartman, who had worked in the tropics (2½ years in Kenya), was a very colorful figure. During his training, he renovated his grandparents' farm and recruited interns for this. He did leprosy research and expected to get his PhD (some say he thought the professor would write the dissertation), but after a disagreement this project was abruptly stopped. Toon Baar had worked in Tanzania and Ethiopia for five years before his training, first as a general doctor and later as a leprosy doctor, Regional Leprosy Officer. After completing the specialization, he went to work in Leeuwarden, where he associated with Dr. Wim Bos.

Vincent Gooskens also had a tropical background (this was probably a pre for prof. Klokke), he had worked in Kenya for three years. After completing his training, he returned to Africa and worked for several years as a dermatologist in Malawi, that is, the only dermatologist in the entire country. He then associated with Bertus Hartman in the Diaconessenhuis in Groningen. Assistant Terpstra became a dermatologist because he was the first to discover the advertisement for a holiday internship on the notice board. There was no need to apply. He later settled in Assen, where he still works (at the age of 67).

Pieter-Jan Coenraads (the current professor of Occupational Dermatology in Groningen) and I took over from Hartman and Wakkers (who went to Delfzijl) on April 1, 1976. We both had started at the clinic on January 1, 1976. I don't remember exactly what we did in the first three months. I do remember that I was always reading (maybe I should finish that study on the side effects of antihistamines) and having trouble not falling asleep in the afternoon. Later Leonie Driessen and Johan Hassing (a somewhat older former general practitioner) replaced Baar and Gooskens (1977) and I think Jaap Dijkstra in 1978 after Terpstra's graduation.

From left to right: Johan Hassing, Pieter-Jan Coenraads and       Dr. Pieter-Jan Coenraads, who would later be appointed

Johan Nater at lunch, mid 1980s. In the back the cleaning          professor of Occupational dermatology in Groningen

staff   

The staff members

The clinical staff consisted of 4 dermatologists, professor A.H. Klokke MD PhD (head of the dermatology department), J.P. Nater MD PhD (allergy department), E.E. Kruizinga MD (outpatient clinic) and H. Doeglas MD PhD (inpatient clinic).

Klokke was an expert in the field of fungi and also knew a lot about leprosy. He had worked in India and Indonesia and this was reflected in his room (estimated at 6-8x the size of the current professor's room), which was covered with photos and where various indigenous artifacts could be admired. When the professor walked through the clinic whistling and smiling from ear to ear, you knew that within half an hour you had to come and see pigmented patients with white spots or swollen nerves. When you smelled the scent of the kretek cigarette in his room, you knew that he was in a particularly good mood (a kretek is a cigarette consisting of two parts tobacco and one part herbs, especially cloves; kretek cigarettes owe their name to the fact that they crackle due to the essential oils when lit).

The staff members

The clinical staff consisted of 4 dermatologists, professor A.H. Klokke MD PhD (head of the dermatology department), J.P. Nater MD PhD (allergy department), E.E. Kruizinga MD (outpatient clinic) and H. Doeglas MD PhD (inpatient clinic).

Klokke was an expert in the field of fungi and also knew a lot about leprosy. He had worked in India and Indonesia and this was reflected in his room (estimated at 6-8x the size of the current professor's room), which was covered with photos and where various indigenous artifacts could be admired. When the professor walked through the clinic whistling and smiling from ear to ear, you knew that within half an hour you had to come and see pigmented patients with white spots or swollen nerves. When you smelled the scent of the kretek cigarette in his room, you knew that he was in a particularly good mood (a kretek is a cigarette consisting of two parts tobacco and one part herbs, especially cloves; kretek cigarettes owe their name to the fact that they crackle due to the essential oils when lit).

Nater had been a dermatologist in The Hague and was an expert in the field of contact dermatitis and occupational dermatoses. Already in the early 1970s he had written a booklet on contact eczema and he is considered one of the founders of occupational dermatology in the Netherlands (together with W.G. van Ketel MD PhD and prof. K.E. Malten MD PhD, with whom he formed the first 'Contact Dermatoses Working Group’). He was head of the allergy department and provided excellent internships in this discipline for the assistants.

Kruizinga had been asked by Klokke to supervise the outpatient clinics and was therefore - as it was called in those days - the chef de policlinique. He had practiced in the Achterhoek county (probably the only dermatologist there) and was already over 60 when I started my training. His greatest achievement - according to himself - was that he had eradicated the fungal infection favus in the Achterhoek, probably thanks to the newly discovered antifungal agent griseofulvin.

Dr. Kruizinga was a very amiable, usually cheerful but also somewhat absent-minded person. Organizing was not his greatest talent nor his hobby. This was evident from the large piles of papers that could be seen in many places on and around his desk. When you walked into his room unannounced, he was usually in one of those piles looking for something.

Doeglas was the head of the inpatient department. That was apparently not a full day’s job, because when you entered his room he often sat on his chair in front of the window looking outside. It usually pleased him when someone came to see him. At that time he did research into urticaria, on which subject he received his PhD later. He had a separate outpatient clinic for patients with urticaria on the third floor. It is doubtful whether he enjoyed it very much. Later, when I had already practiced in Den Bosch for some years, I asked him about his urticaria clinic. His answer was telling: ‘Oh, Ton, we still get patients from all over the country with the most horrible urticaria and I can rarely do anything for them.’ The famous Dr. Albert Kligman (yes, the one behind tretinoin for dermatoheliosis) was right with his famous statement: 'I'd rather have a tiger in my practice than a patient with urticaria'.

There were two more staff members to the dermatology department, E. Bleumink PhD (biochemist) and M.C.J.M. de Jong PhD (biologist). Bleumink was the administrator of the clinic and head of the biochemical laboratory. He later became Secretary of the Medical Faculty, Rector Magnificus and subsequently Chairman of the Board of Directors of the State University of Groningen. De Jong, head of the IF laboratory, conducted immunofluorescence (IF) research on skin biopsies of autoimmune disorders such as dermatitis herpetiformis, pemphigus and bullous pemphigoid (at that time termed parapemphigus). Immunodermatology in Groningen was very important and he made this clear when he told me and the other assistants about it at length, with enthusiasm and emphasis, almost solemnly. It became clear to us that this research was not only very important but also extremely difficult…….

The training to become a dermatologist

The training to become a dermatologist at that time lasted 4 years and in Groningen broadly consisted of four parts: dermatological outpatient clinic, venereal diseases (that's what STDs used to be called), inpatient clinic and allergy.

I think my first internship was at the inpatient clinic. Dr. Doeglas, whom I was not allowed to call ‘mister’ ('just say Doctor Doeglas or, if necessary, Henk') did not always follow along, but the head nurse, Sister Venema, a strong and firm nurse of the old school did, and she taught us the first principles of clinical dermatology. By the way, it was often quite suffering. At that time we still admitted people with arterial leg and foot ulcers to the ward and patients with diabetic feet and foot ulcers were also very welcome. Result: looking at that ulcer again five mornings a week for months in the hope that we could say something hopeful about it. Switching from zinc paste to zinc peroxide paste and back again, adding a purple color (gentian violet) or brown (iodine) in between and, no, a Vaseline gauze did not always help. Later the color gold came into vogue; one of the assistants was sent to buy gold leaf in a paint shop, after the professor had read an article about its beneficial effects on leg ulcers!

One patient has stayed with me: a real-life local from the city with a diabetic foot ulcer that I observed for 3 months hoping that it would close, but who we ultimately sent to the surgeon for a treatment that was slightly more radical than our zinc peroxide paste. Six months or so later I met him on the Grote Markt. I noticed that he didn't walk as if he had a prosthesis. ‘Now listen well, De Groot,’ he said when asked, ‘I was on my way to the surgical department in the ambulance and then I said to the nurses: you can let me out here. I went straight to the pub and made up for the damage from those three months without a drink with you. Then I staggered home, haven’t looked at my foot anymore and after six weeks the hole had completely closed again!'

The outpatient clinic was the best part of the training. The then supervisor of the outpatient clinic, dr. Edze Kruizinga ('Kruis'), was, as I mentioned earlier, a very amiable, but also somewhat absent-minded person. Every advantage has its disadvantage, is the Cruyffian wisdom, and this also applied to the size of the clinic and finding Dr. Kruizinga. In fact, we hardly ever found him, because the clinic was too big. Yes, the pager was already there at the time, but he regularly left it somewhere or simply ignored it. When he called back, Dr. Kruizinga always promised to come quickly. Half an hour later we would page again: 'Yes, I'm coming, una momento'. The result was that waiting times increased to an hour or (much) longer and that in turn led to an angry outburst from my outpatient nurse Anneke Buitenkamp (later Sinke). Not angry at Dr. Kruizinga, but at the fact that she always had to deal with the patients' complaints, 'but they dare not say anything to you (us), because you are doctors'! If those aren't good old days...

And when Kruizinga came, he always took the time to have a nice chat with the patient. He often tried to adapt to the townspeople with some Groningen idiom (and more than just that 'poestige' [shortness of breath] that we already knew from medical school). A frequently used saying by him was 'first zain dan leuven' (see first, then believe), which, if they understood it at all, invariably caused a grin from those same townspeople. On the other hand, the patients did not always understand Dr. Kruizinga when he spoke normal Dutch. For example, I remember that he asked a patient with eczema of the anus three times ‘laat u wel eens een vochtig windje af?’ (not translatable into English) and the man kept looking at him questioningly, until his son translated: 'Do you ever let out a wet fart?' Leonie and I had the utmost difficulty not to burst out laughing.

The venereal disease clinic was Room 12. We had an intercom system for all outpatient clinics, which called patients from the waiting hall. That usually worked fine, except when we called 'Mr. De Vries', because then half the waiting room rose from their chairs. As for room twelve: it was a bit embarrassing at times, because all patients in the waiting room knew that the person who responded to room 12 had a venereal disease. Well, no wonder, everyone always had to wait at least an hour, so you hang out with each other and then you hear something again! But the privacy watchdog did not yet exist.

Well, during that time I called people to Kamer Twaalf, Room Twelve, Zimmer Zwölf, Chambre Douze, Habitation Dosse and even Domatio Dodeka (in the case of Greeks). I had previously done a junior internship there with Peter Schönfeld, an assistant who later went to Amsterdam. To test for gonorrhea, we took material from the urethra with a so-called öse, a metal wire, bent at the end in the shape of a zero. Not everyone appreciated this investigation. I noticed that he always smelled it after taking the sample, so I asked why he did that. ‘I smell whether it is  gonorrhea’, he replied, and I was very much impressed. It wasn't until the next day that I was told by a Terpstra, who was screaming with laughter, that this was a well-known joke of Schönfeld! He had fooled me nicely.

During the allergy internship the dermatology trainees were mainly taught about allergic contact dermatitis, how to recognize and diagnose it. The epicutaneous allergological examinations (patch tests) were performed by two nurses, Tineke Woest and Elma Witters (later Schuiten; she could play a nice game of table tennis), but Dr. Nater often came himself to read the patch tests. He and I got along well. Johan wrote the chapter Drugs used on the Skin in the then already very well-known Meyler's Side Effects of Drugs series (Meyler was professor of pharmacology in Groningen) and asked me if I wanted to co-write it. That was the beginning of a very long collaboration, which has resulted in the joint writing of many chapters in books and articles. At one point, Johan suggested that we also discuss the side effects of cosmetics. I didn't feel much for it at first, but it turned out to be a golden opportunity, which ultimately resulted in our book Unwanted Effects of Cosmetics and Drugs used in Dermatology (3 editions) and my PhD with him in 1988 on my Thesis Adverse reactions to cosmetics, when Johan had become a full professor and Head of the Dermatology department.

In 1979, during the allergy internship, I spent my days in a wheelchair in the clinic for a while. During a volleyball match of the sports competition of the hospital, I had an unfortunate accident and suffered whiplash, for which a plaster cast was apparently given at the time. My girlfriend dropped me off every morning at the entrance of the clinic, where I was met by Dr. Nater or one of the cleaners, who put me in a wheelchair and took me to the designated location by wheeling me through the long corridors of the clinic. All very nice men, the cleaning staff,  but I didn't always understand their Groningen idiom.

The members of the cleaning staff were always willing to move me around in my wheelchair through the long corridors of the clinic

Part of the education was that every trainee had to write a scientific article. That brings me to the library. Of course, PubMed had not yet been invented, nor had the PC or the Internet. But we did have a lot of scientific magazines. Prof. Klokke had devised an ingenious system: if you saw something in a magazine that could be interesting for someone else, you could indicate this on a form and attach it to the magazine with a paper clip: 'attention from... for….'. So if Kruis saw something about allergies, he drew Nater's attention to it. Everything that smelled like urticaria (hives) called for Doeglas' attention, because he was, after all, the urticaria expert. And then you also had to indicate whether you had read the piece. How did we know what was published elsewhere? By looking in the Current Contents. That was a rather sloppy magazine with photocopies of the table of contents of the most important general medical and specialist journals. If you had found an interesting article, it would contain the address of the first author and you could then ask him - by postal mail of course - whether he was willing (no sexism, at the time >95% of the authors were men) to send a reprint or photocopy of the article.  Most were happy to do so. Every issue of Current Contents contained a nice cartoon. One of them from a later date shows that the computer was gradually introduced, but did not always function perfectly.

Lectures were given with slides. The photos were taken by Mr. Dijk, the photographer. The slides were positioned in a linear slide sled or a round carousel. They had to be inserted upside down (camera obscura idea) and also take into account left and right. So there was a right way and two wrong ways to put the slides in. This usually only became apparent during a presentation. Then someone hung down from his feet. It happened to me occasionally, but Dr. Kruizinga was a master at it. And of course close the box with slides properly!!!! The chef de policlinique had forgotten this, so that on the way to a lecture (we were already late) all 60 slides were spread across the square... 'Una momento, de Groot...'

There were regular meetings at the clinic in the evening with presentations and discussion of clinical cases.  Some dermatologists practicing in other hospitals were always present, including a lame one and a one-eyed one. Especially at that time, there were more people in the dermatology world with what is now euphemistically called 'a spot' (both literally and figuratively). Prof. Klokke always had a nice way of stringing together the presentations and in between I was sent to his room to check 'whether the wine was at the right temperature'. The professor gave the most beautiful speeches when a colleague from Indonesia, who had done an internship at the clinic, said goodbye. Then he or she was addressed in Malay with beautiful words such as taki-taki and reta-reta. And if at some point you would hear 'toko V and D', you knew that the speech was coming to an end and a present appeared for the highly honored guest.

Dermatology was in a transition phase at the time of my training. Before 1970, the dermatologist was a doctor who sat behind a desk, made a diagnosis across the desk without getting up, and then wrote a prescription for a nasty and smelly ointment that almost certainly contained sulfur, tar, or both. The chance that mercury had been added was anything but imaginary. A lot of irradiation treatments were prescribed, especially with ultraviolet light (often in combination with tar solution, the so-called Goeckerman treatment) and with X-rays. The latter treatment was not only used for malignant skin diseases, but also for benign conditions such as eczema, warts and fungal infections, which often led to skin cancer in the long term.

In the 1970s, dermatology was gradually modernizing and dermatologists started performing surgical skin operations (much to the chagrin of surgeons and plastic surgeons), practicing allergology and injecting varicose veins. Nater had enough knowledge to properly teach us allergology, but not a single staff member had any experience in dermatosurgery or phlebology. Fortunately, Hartman, Gooskens and Baar were tropical doctors and we were able to learn how to perform excisions and close the wounds from them.

To learn the basics of injecting varicose veins (sclerotherapy), I traveled several times to the 'Heilanstalt für Beinleden' in Hamburg (yes, in Germany). Cursory education did not yet exist at the time. However, Prof. Klokke had us following several courses on fungi and molds in in Baarn. We have good memories of these meetings, especially of the babi pangang from the local Chinese restaurant!The training in dermatology in Groningen was, as was undoubtedly the case elsewhere too, poorly structured. There was often a lack of encouragement, active guidance and monitoring. The cooperation between the staff members left much to be desired. Our information needs could not always be met. We often asked advice from an older assistant when the chef de policlinique could not be found: intervision instead of supervision. We also regularly discussed a dermatological topic at one of the assistants' home, where Hartman and Wakkers sometimes also made an appearance. That's how we learned from each other.

Personnel

Here I would like to mention some (other) personnel members. The director of the outpatient clinic was Brother Elzinga (brother = male nurse). Francien Schönhardt and Anneke Buitenkamp were the nurses at the outpatient clinic. Jan Hamringa was the head of the laboratory. Maaike Fokkema ran the mycology laboratory. There was one young woman working at one of the laboratories, who always arrived at half past nine and then sat down to read the newspaper with a cup of coffee. At four o'clock her husband would pick her up and then the working day was over... (o tempora, o mores) (the husband was a VIP in the university hospital). The work in the biochemical lab was mainly done by Guus Kloosterhuis, who recently retired. Aleid Tensen and Joyce van Schalkwijk were the STD nurses, who, among other things, carried out contact tracing in patients with venereal disease. There was a kind of Warmoesstraat atmosphere (a police station in Amsterdam) in their room and these ladies knew what they were doing! Janny Zuiderveen worked at the pathological-immunological laboratory. Mrs. de Ranitz was the professor's secretary. I thought she was always a bit strict with us. Although she was loyal to her boss, she regularly disagreed with him and then consulted with Mr. Dijk, the photographer (invariably with a pipe in his mouth).

Finally, Ans Slagter (later Stoffers-Slagter). She was the secretary of the nursing clinic. A beautiful young woman from Groningen who was always nice and cheerful. Last year she went on early FPU (I don't know what this means, probably early retirement) and for that occasion she described herself in OnderHUIDS, the Newsletter of the Dermatology department, as an 'old woman'. Completely wrong, by the way, because I had recently seen her with a modern haircut, hip glasses, and very trendy clothes. One of my fondest memories - which I can still talk about with pleasure with friends after a few glasses of wine - has to do with Ans. No, not that we bought duvet covers for me together (which my wife, my girlfriend at the time, still only moderately appreciates even now, 34 years later). But the unforgettable story of Ans and a staff member, let's call him doctor X. Doctor X went on vacation to Mexico. He had bought a postcard with an image of 2 pyramids next to each other in the Yukatan and sent it to her with the immortal text: 'Ans, when I saw this, I thought of you. Kind regards from doctor X. Of course, the fact that he signed it with 'doctor...' makes it absolutely complete. We had a good laugh about it together, Ans and I. Well, so those were indeed the good old days (please don't accuse me of sexism), that would be unthinkable now. Ans would still see the humor in it even now, I'm convinced of that.

What came next

Shortly before the end of my training (12/31/1979) I was asked to succeed Dr. Kruizinga as chef de policlinique. Johan Nater really wanted me to stay, but was honest enough to advise me to only accept the job if was given the opportunity to do research and get my PhD. However, Klokke denied me this and so I decided to start my own practice in a non-academic hospital. My decision was not appreciated by Klokke and the minutes of the next Staff meeting it was entered that 'de Groot’s decision had caused major problems for the clinic'. Because one never knows what the future will bring, I went to the manager of the clinic, explained the situation and asked him to make a note of it…. (By the way, the clinic has certainly benefitted from my departure, because it paved the way for Dr. Pieter van Voorst Vader to get the appointment, and who would become an indispensable and excellent staff member in the clinic for 30 years). I then started practicing at the Carolus and the Willem-Alexander Hospital in 's-Hertogenbosch in 1980.

It became clear that indeed one cannot be careful enough when in 2006 - I now lived in South-West Drenthe and no longer had a practice - I asked Prof. Jonkman, the then professor of the dermatology department, if I could do some volunteer work for the clinic. And yes, believe it or not, the relevant minutes had surfaced again. Marcel and I could both see the humor in it after my explanation. Since then I have had an unpaid part-time appointment at the UMCG for regularly teaching general dermatology to junior interns.

So much for my ‘memories of a former assistant in training to become a dermatologist’. It was a great time, the mid-seventies. So long ago, and yet as if it were yesterday. And, yes, as far as I'm concerned, the good old days.

Acknowledgment

Many thanks to Leonie Driessen, Vincent Gooskens, Hylke Terpstra and Pieter-Jan Coenraads for sharing their memories. Marijke Baar provided the photograph of the clinic employees (taken on June 14, 1977). The names of the people in the photos were partly provided by Mr. A.C. Dijk (photographer), Ans Slagter and Janny Schutter. Pieter van Voorst Vader has made useful suggestions for improvement in the text.

P.S. I cannot vouch for the infallibility of my memory and therefore cannot guarantee the absolute accuracy of the content of this story. The same applies to the names with the photos.

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