SPECIALIZATION VERSUS GENERAL PRACTICE

Planning and the Structure of the Medical Profession

During the 1920s the growing complexity of medicine led to a bewildering range of new information for a physician to assimilate. Hospitals and climes grew in number, and medical costs ranged upward to pay for them. Resources, both in medicine and for the public, were maldistributed, with physicians forced to make compromises in the treatment of patients between what was medically desirable and what the patient could afford to pay. All these issues affected the way medicine was organized and the quality and distribution of the service offered. Such problems were brought to a head by the social turbulence of the early 1930s. One of the most important issues facing medicine concerned the organization of the profession. The Depression cut doctors' profits, raised hospital costs, and strained medical services. As they did in other industries, New Dealers advocated economic planning, the imposition of codes and practices, and general federal regulation of the health profession. But health professionals mobilized to oppose federal regulation, national health insurance, and governmental oversight of their profession. In the process the health industry became more specialized, more professionalized, and more able to protect itself from outside regulation.

Life, Death, and Medicine

Unlike other industries, of course, medicine was not simply a for-profit enterprise. Medicine was a science, with developing methods and procedures; a profession, with common social assumptions and guild practices; and a public service, whose life-and-death character made for volatile politics. It was also the province of increasingly wealthy and powerful members of American society. Physicians insisted on protecting their ability to negotiate their division of labor instead of having it hierarchically imposed upon them by a corporate structure. As a group doctors fared better than other Americans during the Depression, but there were differences within the medical hierarchy. A 1930 survey in Wisconsin showed an income range from less than one thousand dollars to more than twenty thousand dollars. Surgeons and other specialists were at the top of the scale, and general practitioners ranged toward the bottom. GPs had the most difficult time collecting bills; full-time specialists the least. Relationships between general practitioners and specialists, already strained by questions of prestige and status, became more stressful. The technological advantages of a hospital affiliation became linked to economic advantages. Professional interests and ideals also influenced the increasingly complex division of labor between general practitioners and the specialty occupations that emerged with the growth of modern hospitals, clinics, and laboratories.

The General Practitioner versus the Specialist

By 1930 nonphysician specialists were under the doctors' authority, but general practitioners resisted any efforts to give specialists exclusive privileges over some kinds of medical work. There was no way to prevent GPs from practicing as specialists. In England there was a two-tiered system where patients had to be referred to specialists through their general practitioners, and only specialists could consult in the hospitals. In the United States patients could go directly to specialists. Specialists were concentrated in the major cities and towns, GPs in the more-rural areas. There was no clear solution to questions of bringing quality medical services equally to all citizens, but professional organizations began to form rapidly within the medical profession. The AMA had already emerged as the powerful political spokesman for the physician, and in response both to the continuing development of specialist fields and to the economic problems of the Depression, medical specialties became formalized.

The Specialty Boards and the "System" of Medical Care

Many specialty boards developed during the 1930s, including the American Boards of Obstetrics and Gynecology, Internal Medicine, Surgery, Pediatrics, and others. These boards professionally regulated physicians admitted to the specialty and defined and controlled the quality of practice. Three years of training after internship were required. Candidates for a specialty board were looked at for moral and ethical standing, and they had to be members of the AMA. The boards also were a response to what seemed the inevitable alternative of specialist licensing by the states. But the question 'Who should control specialization?" was only partially answered by the end of the decade. Once approved, a specialty board was not subject to any common, outside control. No one had primary responsibility—the AMA, the licensing boards, the National Board, the hospitals, or any other group. There had been little involvement of the public or their elected representatives during the evolution of the new structures. Physicians had still preserved their traditional autonomy and professional sovereignty and protected their practices from governmental oversight. There was still no consideration of specialty certification in terms of the overall organization and delivery of medical care for the country. The American system of medicine remained a "non-system."

Sources:

Paul Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982), pp. 220-225;

Rosemary Stevens, American Medicine and the Public Interest (New Haven: Yale University Press, 1971), pp. 75-266.

Doctor, Family Practice

A family practice doctor is the primary health care professional responsible for treating people for most conditions. Family physicians work in private offices, group practices, and hospitals, caring for every family member from before birth until the time of death. Under America's health insurance system, most people go first to their family practice doctor for all complaints, from infections to chronic illnesses to preventive medicine.

Family practice doctors approach the treatment of the family as a unit, focusing on health promotion, disease prevention, and psychological issues affecting health, as well as treatment of disease. Depending on the condition, treatment may include prescribing medicines, recommending lifestyle changes such as exercise and diet, or referral for other types of treatment, including surgery, physical therapy, or psychotherapy. The doctor works in partnership with other health care professionals, including nurse practitioners, nurses, and medical assistants.

DELBRÜCK, MAX (1906–1981)

German-born U.S. biologist who received, with Salvador Luria and Alfred Hershey, the 1969 Nobel Prize in physiology for his work on bacteriophages, viruses that infect bacteria. In 1939, Delbrück invented an easy way to grow bacteriophages in the lab, and in 1949 he and Hershey showed that the genetic material of different viruses can combine to make entirely new viruses.

To become a family practice doctor, one must first earn a bachelor's degree (either a bachelor of arts or bachelor of science) from a four-year college, and then earn a doctorate of medicine (M.D.) degree from a medical school. This usually takes four years, and combines classes and clinical experience. Following this, doctors undergo three years of postgraduate training, called internship and residency. During residency, they receive training in the full range of medical disciplines, including pediatrics, obstetrics/gynecology, internal medicine, preventive medicine, surgery, and psychiatry. Family practice doctors often choose this career because they enjoy participating in the comprehensive care of people of all ages, and they desire to help people attain and maintain good health.

see also Doctor, Specialist; Nurse; Nurse Practitioners

Richard Robinson

Bibliography

American Academy of Family Physicians. <http://www.aafp.org>.