From Cradle to
Grave: Term 2,
Lecture 1
The Rise
of the
Family
Doctor
Lecture themes and outline
THEMES/QUESTIONS
• The consolidation of a medical profession?
• The rise of the family doctor?
OUTLINE
• 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
• The emergence of a family doctor?
Professionalisation - definition from
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’.
*‘Physicians, science, and status: issues in the professionalization of Anglo
American medicine in the nineteenth century’, Medical history, Vol. 27, No.
1. (Jan. 1983), pp. 51-68.
A medical profession: relevant criteria
1. The possession of a body of highly specialized 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 cutprice 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 century
1. 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
John Hunter (1728 -1793)
Quack doctor open for business. Coloured etching by G.M. Woodward, 1802
Medical Reform (1)
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 – ‘surgeonapothecary’
• By 1848 most practitioners held multiple qualifications:
LSA, MRCS (Membership of the Royal College of
Surgeons), 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
his botched
operation to
remove a
bladder stone for
which he was
sued
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 (2)
1858 Medical Act
Created 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,
Making a Medical Living: Doctors and Patients in
the English Market for Medicine, 1720-1911,
CUP,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 middleclass providing new market, too many doctors.
• Medical Societies set up to regulate intraprofessional ethics and to combat unqualified
practice,e.g.Huddersfield Medico-Ethical Society
est.1852
• 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
BURKE AND
HARE – GRAVE
ROBBERS
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.
Conclusion
Did the 19th century see the emergence of a
modern profession?
YES….By the late 19th century 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