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Harriet S.MeyerMD, Contributing EditorDavid H.MorseMS, Journal Review EditorRobertHoganMD, adviser for new media
While much has been written about developments in British medicine during the period in question, notes Professor Digby in this important study, historians have tended to focus on the elite physician or on hospital services rather than on the main provider of primary care, the general practitioner. This neglect has left us knowing little about the daily life of the average doctor or about health care outside London and other major cities, particularly during the second half of the 19th century.
To rectify this situation, the author traveled to dozens of archives throughout England, Scotland, and Wales in search of general practitioners' case registers, notebooks, financial accounts, correspondence, and legal papers, and any other materials that might illuminate the business side of general practice as well as doctor-patient relationships. In making such exceptional use of provincial sources, Digby followed the example set by Irvine Loudon, whose ground-breaking Medical Care and the General Practitioner, 1750-1850 came out in 1986. As with that book, the result is a work refreshingly national in scope.
The versatile providers of regular medicine who became known as general practitioners evolved from the popular surgeon-apothecaries of earlier times and initially came from a wider range of social backgrounds than was later the case. Rising educational requirements during the second half of the 19th century left fewer people from lower-class backgrounds able to aspire to a medical career. More rigorous standards also helped improve the status of the general practitioner, making the profession increasingly attractive to middle-class men. Between 1881 and 1911, Digby records, the number of doctors rose by 63% compared with only 23% and 20% respectively in the case of lawyers and clergymen.
Although the United States had more than twice as many physicians per person as Britain during those decades, the rapidity with which the field was growing sparked fears of occupational overcrowding, furnishing male doctors with another excuse, besides biological and moral unsuitability, Digby points out, for opposing the entry of women into the profession. While the number of British women studying medicine rose sharply after 1900, she adds, a smaller proportion than males ended up in general practice, primarily because of the difficulties women experienced, not just before the First World War but well into the 1940s, in establishing financially viable, independent practices. In the mid-1930s, female general practitioners earned on average only half as much as their male counterparts, with women older than 45 years earning significantly less. Readers may wish that the author had found more information about female general practitioners, rather than women doctors in general, and that she had been able to say more about the prejudice that married women practitioners faced. Nevertheless, the book offers some interesting insights into the additional challenges that women physicians had to overcome.
What it took for general practitioners, whether male or female, to set themselves up in gainful employment is covered in great detail. The book provides some fresh data on the geographical movements of fledgling doctors in search of professional abodes, the spread of partnerships, the contribution of the National Insurance Act of 1911 to the evolution of general practice, and the reaction of general practitioners to their incorporation into the National Health Service. The sections that readers will probably find most innovative and interesting, however, are those that describe the day-to-day events in an ordinary physician's life. Whenever possible, Digby lets the doctors speak for themselves, quoting them extensively on such matters as the selection of a suitable location for an office, the layout and equipment of surgeries and waiting rooms, the amount charged for visits, the steps taken to collect bills, and the bewilderingly wide variety of minor illnesses that patients presented for treatment, few of which physicians learned about during student years.
The general practitioner has long been the mainstay of the British medical system. Ann Digby deserves our thanks for rescuing the general practitioner's history from oblivion.
British General Practice: The Evolution of British General Practice, 1850-1948. JAMA. 2000;284(2):244. doi:10.1001/jama.284.2.244-JBK0712-5-1
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