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The Business of Private Medical Practice

The Business of Private Medical Practice: Doctors, Specialization, and Urban Change in Philadelphia, 1900-1940

James A. Schafer
Copyright Date: 2014
Published by: Rutgers University Press
Pages: 272
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  • Book Info
    The Business of Private Medical Practice
    Book Description:

    Unevenly distributed resources and rising costs have become enduring problems in the American health care system. Health care is more expensive in the United States than in other wealthy nations, and access varies significantly across space and social classes. James A. Schafer Jr. shows that these problems are not inevitable features of modern medicine, but instead reflect the informal organization of health care in a free market system in which profit and demand, rather than social welfare and public health needs, direct the distribution and cost of crucial resources.

    The Business of Private Medical Practiceis a case study of how market forces influenced the office locations and career paths of doctors in one early twentieth-century city, Philadelphia, the birthplace of American medicine. Without financial incentives to locate in poor neighborhoods, Philadelphia doctors instead clustered in central business districts and wealthy suburbs. In order to differentiate their services in a competitive marketplace, they also began to limit their practices to particular specialties, thereby further restricting access to primary care. Such trends worsened with ongoing urbanization.

    Illustrated with numerous maps of the Philadelphia neighborhoods he studies, Schafer's work helps underscore the role of economic self-interest in shaping the geography of private medical practice and the growth of medical specialization in the United States.

    eISBN: 978-0-8135-6176-9
    Subjects: Health Sciences

Table of Contents

  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
  3. List of Figures
    (pp. ix-x)
  4. List of Maps
    (pp. xi-xii)
  5. List of Tables
    (pp. xiii-xiv)
  6. Acknowledgments
    (pp. xv-xviii)
  7. List of Abbreviations
    (pp. xix-xxii)
  8. Introduction
    (pp. 1-12)

    The health care “system” in the United States has many problems, with rising costs and declining access being the two most intractable. By any measure, we have the most expensive health care system in the world. As I write this introduction, the latest data on national health expenditure (NHE) show that the United States spent $2.6 trillion in 2010. This tally was equivalent to $8,402 per person and comprised 17.9 percent of the gross domestic product (GDP). To put these daunting figures in perspective, since 1960, when the United States spent $148 per person and 5.1 percent of GDP on...

  9. Part I 1900–1920

    • Chapter 1 The Primacy of Private Practice
      (pp. 15-38)

      In a small, well-worn memorandum book, young Dr. DeForest Porter Willard Jr. (1884–1957), kept track of the highlights of his life and career in Philadelphia in the early twentieth century (table 3). His parents began the memo book to record childhood milestones, such as first words spoken, but Dr. Willard assumed authorship during adolescence. Apart from jotting down personal triumphs, such as winning golf championships in 1912 and 1913 and purchasing a Fiat roadster in 1916, Dr. Willard devoted most of his entries to career achievements, such as deployment dates for his medical service during World War I. Many...

    • Chapter 2 The Doctor as Business Owner
      (pp. 39-70)

      As American doctors aspired to new professional status, an internal debate raged about the proper role of the commercialism in medicine, and Philadelphia doctors were no exception. For example, in a contentious paper read before the Philadelphia County Medical Society in 1901, Dr. John B. Roberts distinguished “proper and just enterprise and thrift in one’s professional work and what is an improper commercial spirit.” As a surgeon, Dr. Roberts had witnessed the most deplorable billing practices of his time: price gouging, upselling expensive prosthetics over affordable alternatives, referring patients to private hospitals in which one had part ownership, demanding payment...

    • Chapter 3 Downtown Specialists and Neighborhood GPs
      (pp. 71-100)

      In her unpublished autobiography, Dr. Catherine MacFarlane recounted her medical career in Philadelphia, from studying as a medical student at Woman’s Medical College (1895–1898), to training as an intern at Woman’s Hospital (1898–1899), to working and teaching in an obstetrical clinic (1899–1901), to setting up her first private medical practice (1901), to specializing in gynecology (1908), to being appointed as professor of gynecology at her alma mater (1922), by which time she had earned a reputation as one of the city’s top gynecologists.¹ As we have seen, the career moves of early twentieth-century American doctors were inseparable...

  10. Part II 1920–1940

    • Chapter 4 New Career Paths, New Business Methods
      (pp. 103-133)

      When Dr. Carl C. Fischer finished his internship year at Hahnemann Hospital and then passed his state board examinations in 1929, his career was no different from all of the other newly minted medical doctorates in Pennsylvania after 1914, the year in which the state became the first to require internship for licensure. Young doctors no longer entered private practice directly, but rather took a year of additional clinical training in the form of the general rotating hospital internship. Dr. Fischer, though, had ambitions to specialize in pediatrics. Unlike earlier generations, who first spent several years in general practice, Fischer...

    • Chapter 5 From Center City to Suburb
      (pp. 134-175)

      Besides signaling new career paths and business practices, especially in large cities, increased specialization and hospital-based medicine also transformed patient care. Not only had traditional services been shifted from the home to the hospital, such as attendance at childbirth, but a variety of new surgical procedures and diagnostic tests were centered in hospitals, such as tonsillectomies or X-rays.¹ As technologically sophisticated care became the hallmark of “modern” scientific medicine in the early twentieth century, health care costs began to rise. Cost inflation forced structural changes in patient care, whether in the hospital or in the doctor’s office. Hospital administrators built...

  11. Conclusion
    (pp. 176-184)

    The Business of Private Medical Practiceanalyzes the urban origins of one of our nation’s most intractable health care access problems: the uneven distribution of doctor’s offices, or private medical practices. Unlike early studies of the location of doctor’s offices published from the 1920s to the 1940s, which focused on rural-urban divisions at the county, state, and regional level, this book examines distribution problems within American cities, using the example of Philadelphia, Pennsylvania, from 1900 to 1940. Although a spate ofintra-urban studies were published from the late 1960s through the early 1980s, very few analyzed office locations before mid-century....

  12. Appendix: Notes on Sources and Methods
    (pp. 185-194)
  13. Notes
    (pp. 195-238)
  14. Index
    (pp. 239-250)
  15. Back Matter
    (pp. 251-254)