From Cradle to Grave: Lecture 10

The Rise of the Family Doctor

Lecture themes and outline

The consolidation of a medical profession?The rise of the family doctor?

• Definitions/criteria of ‘profession’

• Changes in medical practice in the C19th- Medical education- Licensing of practitioners

• Reform of medical practice - 1815 Apothecaries Act- 1858 Medical Act

• The medical profession in the late C19th- GPs, public offices, consultants- Problems for the profession: overstocking, competition,

public image

?Emergence of a family doctor

Professionalisation, S.E. Shortt (1983)

‘A process by which a heterogenous collection of individuals is gradually recognised, by both themselves and other members of society, as constituting a relatively homogenous and distinct occupational group’.

A medical profession: relevant criteria

1. The possession of a body of highly specialised knowledge: we expect doctors to have a deep knowledge, acquired through long training in medical school. A doctor’s qualifications prove that he or she has completed this training to the standards required of the profession.

2. Professional unity and a strong ethos of public service: we do not expect doctors to compete with one another for patients by advertising their services or by offering cut-price practice. We do expect practitioners to co-operate when caring for patients, and to always work for the patients’ best interests.

3. A monopoly of practice: only members of the medical profession can call themselves doctors. We distinguish between orthodox medical practitioners and those who offer alternative forms of medical treatment by calling them practitioners of ‘complementary’ or ‘alternative’ medicine.

4. Professional autonomy: medical practice is based on highly specialist knowledge, which is not shared with the general public. Therefore, only doctors can judge whether other doctors are trained to a suitable standard and are competent to practice.

5. High social status: doctors earn high salaries and also enjoy a special social respect.

Situation in early 19th century1. No collective power: divisions between physicians,

surgeons and apothecaries (tripartite structure)

2. Variety of routes to a medical licence – licensing bodies corrupt and irrelevant

3. Beginning of new division within the medical profession – general practitioners and consultants

4. Competitive medical marketplace

5. Public perceptions varied – doctors depicted as money grubbing or unskilled

Argued modern medical profession emerged c.1840-1880

The Village Doctor. Etching by T. Rowlandson, 1774

Medical Reform

1815 Apothecaries Act

License of the Society of Apothecaries (LSA) needed to practice as an apothecary: apprenticeship, academic courses, hospital experience and examination Separated apothecary from retail druggist – ‘surgeon-apothecary’

By 1848 most practitioners held multiple qualifications: LSA, MRCS, medical degree and midwifery licence. c.15,000 GPs in England and Wales by 1848.

Became basis of general practice of medicine - already by 1820s division between GPs and consultants began to be laid down.

Medical Journals: pressure for reform, Lancet 1823; Provincial Medical and Surgical Journal 1840, BMJ 1857

Sir Astley Cooper (1768-1841)

Lancet attacked system of hospital appointments and consultant posts as corrupt.

e.g. Bransby Cooper, appointed to Guys Hospital as nephew of Astley Cooper

(Astley Cooper earned c.£1,000 a year)

The Cooper’s Adz!! Versus the Lancet!!, 1828.

Cooper is shown being stabbed in the bottom, not just for comic effect but also as an allusion to the operation to remove a bladder stone

Sir Charles Hastings (1794-1866), founder of the British Medical

Association (originally called

the Provincial Medical and

Surgical Association 1832)

Renamed BMA 1855

Medical Reform

1858 Medical ActCreated single medical register Equal recognition of all practitioners

General Medical Council – upheld standards, education, ethics, practice

1886 Medical Amendment Act – all medical students required to have qualifications in surgery, midwifery and medicine

Limitations • Still multiple routes to qualification• Quacks and irregulars still practised• Period of great upheaval and competition between

doctors

Irvine Loudon

Medical Care and the General Practitioner (Oxford: Clarendon Press, 1986), pp. 298-301

Ivan Waddington

The Medical Profession in the Industrial Revolution (Dublin: Gill and Macmillan, Humanities Press,

1984), pp.138-52.

Five career patterns for doctors (Anne Digby 1999):

1. The ‘classic’ GP who practised general medicine amongst a mix of social classes.

2. The GP/surgeon who practised general medicine and had a part-time appointment as a surgeon in a small hospital

3. The GP/specialist, who worked as a general practitioner but also did some consulting work in one area of medicine, such as obstetrics.

4. GPs who became consultants, men who started their careers in general medicine but switched to full-time consulting.

5. The ‘pure’ consultants, who belonged to prestigious medical institutions, held posts in major hospitals and had a private practice.

Problems of medical profession

• ‘Overstocking’ of medical profession. More doctors qualifying in 19thC – though middle-class providing new market, too many doctors.

• Medical Societies set up to regulate intra-professional ethics and to combat unqualified practice.

• Female practitioners – seen as source of competition though numbers low.

• Professional standing – image poor (body snatching).

The BMA Secret Remedies Campaign, 1909

Elizabeth Garrett Anderson (1836-1917)

• First woman to qualify in medicine in Britain

• LSA 1865• Specialised in treatment

of women and children – advocate of women doctor and women’s rights more broadly

• Set up New Hospital for Women and Children 1872

Luke Fildes, Physician watching over a Sick Child, 1893

Family practitioner

20thC general practice• Going to doctor now most commonly shared experience

– in Britain access to GP increasingly seen as right from introduction of National Insurance 1911 and confirmed by NHS

• Early 20thC most patients saw doctor in their own homes or doctors’ parlour, many would also carry out small surgical operations at local cottage hospital, most also practised midwifery

• NHS expelled last GPs from hospitals, but GPs got the patients (specialists the hospitals) – redefined role to refer patients

• Home visits common early in the 20thC – in 1908 Harry Roberts, Hackney GP, saw 80 patients at home a day. By 1970s home visits fell to c.8-15 daily, and now extremely rare.

John Berger: A Fortunate Man• A Fortunate Man: still the most important book about general practice

ever written

• In it a GP working in the Forest of Dean in the mid-1960s comes to life. We read about his encounters with his patients and his struggle to respond to their illnesses and lives. The demanding and fallible humanity of John Sassall, the doctor, is described as clearly as the everyday courage and despair of his patients. The book's photos by Jean Mohr portray Sassall at work and in conversation, his patients as individuals and in groups, and the ever-changing dialogue between sky and landscape, both beautiful and full of foreboding.

• You can hear the voices of patients through the text, as the book moves from half a dozen brief stories of their lives to John Sassall's evolution as a doctor. He starts his career thriving on medical emergencies, impatient with non-specific symptoms and the absence of clear-cut physical diagnoses and underlying pathology. He moves gradually towards an empathic listening and companionship with his patients and their families, striving to recognise who they are and the meaning of their illness to them.

Conclusion

The emergence of a modern profession?Yes by late 19thC• Meets many of criteria of a profession: unity, educational standards,

GMC, register, regulation, medical press

BUT• Mixed route to medical qualification• Intra-professional tensions e.g. hospital vs. public posts, generalists

vs. specialists• Unqualified still practising and popular with the public

NOT CONSOLIDATED PROFESSIONALISATION – this has to wait until 20thC which saw more clear cut split between GPs and

hospital specialists

Meaning of medical practice/idea of family doctor

• Site of practice changed significantly – GP until late C20th associated much more with home setting, knew patients, practices smaller

• In last quarter of C20th GPs practices complex and large – investment in equipment and staff

• Trend accelerated since NHS market imposed in 1989-90, though remain purveyors of public service (very few private GPs)

• Doctor-initiated and medical content of consultation increased and patient-initiated and social content decreased