H-France Review Vol. 7 (November 2007), No. 138
George Weisz, Divide and Conquer: A Comparative History of Medical Specialization. New York: Oxford University Press, 2006. xxx + 359 pp. Tables, notes, and index. $29.95 U.S. (cl). ISBN 0-19-517969-2.
Review by Alex Dracobly, University of Oregon.
The subject of George Weisz’s new book, Divide and Conquer: A Comparative History of Medical Specialization, will be familiar to anyone who has consulted a physician any time in the last several decades. Specialization so dominates western medicine today that even generalists often function as specialists in directing patients to the appropriate specialist. In the United States the traditional General Practitioner has effectively disappeared from the medical landscape. Although the U.S. is an outlier in this respect, specialty practice is now a central if not dominant feature of nearly all contemporary medical systems in Europe, the U.S. and the rest of the developed world.
Weisz’s aim is to explain not only why but how this situation has come about. His book is a comparative study of specialization in four western nations: France; Germany; Great Britain; and the United States, over the last two centuries. All four nations have followed the trend toward specialization in this period, a tendency that Weisz attributes to such common factors as urbanization, professional consolidation, the pressures of bureaucratic rationalization, and the increasing division of labor in the medical sciences. At the same time, however, there have been important variations in the development, regulation and institutionalization of medical specialties in the four countries. It is these variations that are the real focus of Weisz’s study.
In its broad outlines the story Weisz tells is fairly straightforward. The modern medical specialties first emerged in Paris in the first half of the nineteenth century before spreading first to German-speaking lands, then the United States and finally Great Britain in the second half of the century. Although medical specialization encountered resistance from traditionalists and entrenched interest groups within the medical professions, by the turn of the century medical specialties were firmly established and widely recognized as legitimate forms of professional activity in all four of these states. In the first half of the twentieth century, the central issue was not the existence of specialties but their regulation. The process by which the specialties were institutionalized was dependent on the particular circumstances of each country. The outcomes, however, were similar. By 1950 all four states under consideration had established certification procedures for medical specialists and the specialties themselves were fully integrated within the respective national systems of medical education, research, and practice.
The details vary widely and it is not possible here to do much more than touch on a few aspects of these developments. Medical specialization first emerged in Paris due to a number of convergent factors: the large number of doctors, professionally united but seeking advancement in the highly competitive environment in Paris; Paris’s status as a “center of knowledge production based on a coordinated network of institutions whose size was unprecedented”; the logic of state administration and the functional specialization of hospitals; and the possibility of pursuing specialty practice both in the Paris hospital system and in private practice (p. 11). Much of the impetus behind these developments, Weisz argues, came from below, so to speak, from the “individual career choice[s]” of doctors themselves (p. xvi). At the same time, however, the structure of medical education, research and practice in Paris provided a solid institutional basis for the pursuit of specialist knowledge. In Weisz’s words, “emerging specialization in Paris was based on the coming together of a system of career competition based on some notion of advancing medical knowledge…with classificatory categories that emerged from efforts to impose bureaucratic rationality on huge institutional structures” (p. 18).
The significance of these issues becomes clearer when compared to developments elsewhere. In Germany, for instance, a similarly close connection between specialist hospitals, the state and universities existed, but there was no place in Germany that possessed the “critical mass of individuals who considered themselves members of an emerging category of practitioners distinct from general physicians and surgeons” (p. 45). Much more than in France, medical specialization in Germany was driven by a research imperative and the changing nature of the medical academic disciplines. Until 1880, medical specialization in Germany remained closely associated with academia. It was only in the last decades of the century that specialties as forms of medical practice became more widespread in Germany.
An even greater contrast is provided by the example of London, where, as Weisz observes, “an almost exact negative image of the situation that allowed specialization to flourish in the French capital” existed (p. 26). British hostility to specialization was more widespread than almost anywhere else, a fact that can be chalked up to the absence of a unified medical profession and the lack of a research orientation among the British medical elite. In time British doctors reluctantly accepted specialization but mainly in response to outside pressures. Prestige was an issue, as developments in medical education and research increasingly required specialization to participate in the international scientific community. Furthermore, “growing government involvement in health care produced many of the same kinds of pressures for administrative rationalization that supported specialization in other countries” (p. 37).
Similarly parallel but distinct processes took place with respect to the regulation of medical specialties. In Germany, for instance, the first of the four nations examined to regulate its specialties, the medical profession avoided “legal and state machinery in favor of professional self-reliance” (p. 105). The success of these tactics might appear surprising when viewed from France. But they reflected a long-established and widely accepted right to practice on the part of irregular and alternative practitioners, as well as the lack of interest of the German academic elite in regulatory questions, the widespread existence of specialty practitioners, the existence of precedents for the regulation of specialty practice in some German states, and concerns over the impact of specialization on intellectual and educational “wholeness.” The German medical profession’s certification of specialties (the “Bremen guidelines” of 1924) was a compromise solution that established fourteen recognized specialties and sought to define relations between specialists and GPs. According to Weisz it represented an attempt by doctors to establish some kind of control over an issue that appeared to threaten the integrity and unity of the medical profession. A similar process took place in the United States, where the state, rather than the profession, controlled certification.
France, by contrast, was relatively late in establishing a regulatory framework for medical specialties. The issue did not receive widespread attention until the 1930s, a decade after Germany and the United States, and specialty certification was not established until 1947. According to Weisz this delay was due to the “long-standing system of state-sponsored regulation of doctors” in France, which made the question of specialization less urgent than in either Germany or the United States (p. 148). When the French medical profession began agitating for specialist certification (and Weisz is clear that the impetus came from the profession, not the state), regulation was delayed by the decision to pursue an ambitious program of national state certification rather than the “easier-to-achieve systems of professional certification” implemented in Germany and the United States (p. 163). Rivalries between doctors and dentists, in particular, greatly complicated the creation of a centralized system of certification. It was only through the “creation of a new administrative body, the Ordre des Médecins,” that these divisions were overcome (p. 163). Although the system proved unwieldy and difficult to implement, Weisz concludes that “this quest for a uniform national system seemed an appropriate strategy to apply to the centralized national system of medical institutions that had evolved during the previous century” (p. 163).
The scope of Weisz’s achievement in this book is impressive. He has covered in great detail and with analytic rigor an important set of developments in four different nations over a period of two centuries. Anyone familiar with his earlier studies on the modern university in France and the French Academy of Medicine will recognize his meticulous scholarship.[1] What makes this book so very powerful, however, is the comparative angle. It is one thing to state that professional unity in France helped foster specialization. That observation gains in richness when compared to the lack of professional unity in Great Britain. Weisz is also very good at handling a wide variety of complicated and overlapping causal factors. No single set of factors dominates Weisz’s account, so that the reader comes away with an excellent sense of how, for instance, the demands of bureaucratic rationalization, academic institutions, professional organizations, public health demands, as well as the career ambitions and interests of individual practitioners, interacted to produce the “system of specialties” that exist today. It might be observed that although Weisz does not frame his book around “transnational” issues (his analytic language of choice is sociologically inflected), this topic lends itself well to the study of how international developments interact with national and local factors to produce simultaneously similar and distinct outcomes.
There is little doubt that this book will be widely read by historians of medicine. As the first general book on this topic in more than fifty years, it is also likely to spur further research into similar areas. This is especially the case as Weisz has explicitly set out to write a history of medical specialization as opposed to a history of medical specialties, most of the history of which has yet to be written. Two of the later chapters focus on a small handful of specialties, selected for their value as case studies. But the focus of the book is on the process of specialization.
Non-specialists will also find much in Divide and Conquer. Anyone working on a medical specialty will want to consult with Weisz’s work, if only to get a sense of the broader context of specialization. It is also likely that Weisz’s discussion of the “system of specialties” will also be useful to scholars working on any number of professions characterized by specialization. The book, however, is longer than it looks and Weisz goes into more detail than many readers are likely to want. That said, discussion of specific countries is easy to find, and the big arguments are drawn together and ably summarized in the introduction and conclusions.
NOTES
[1] George Weisz, The Emergence of Modern Universities in France, 1863-1914 (Princeton, N.J.: Princeton University Press, 1983); idem, The Medical Mandarins: The French Academy of Medicine in the Nineteenth and Early Twentieth Centuries (New York and Oxford: Oxford University Press, 1995).
Alex Dracobly
University of Oregon
dracobly@uoregon.edu
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H-France Review Vol. 7 (November 2007), No. 138
ISSN 1553-9172
